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BlER'S 

Hyperemic  Treatment 


IN  SURGERY,  MEDICINE,  AND  THE  SPECIALTIES 
A    MANUAL    OF     ITS    PRACTICAL    APPLICATION 


BY 

WILLY  MEYER,  M.D. 

Professor  of    Surgery   at  the   New   York    Post-GraJuate  Medical  School  and 

Hospital  ;    Attending   Surgeon   to  the   German    Hospital  ;    Consulting 

Surgeon  to  the  New  York  Skin  and  Cancer  Hospital,  and 

to  the  New  York  Infirmary 

AND 

Prof.  Dr.  VICTOR  SCHMIEDEN 

Assistant  to  Professor  Bier,  University  of  Berlin,  Germany 


SECOND  REVISED  EDITION,  ENLARGED 
ILLUSTRATE  D 


PHILADELPHIA    AND    LONDON 

W.  B.  SAUNDERS   COMPANY 

1909 


Copyright,  1909,  by  W.  B.  Saunders  Company 


First  printing  March,  1908 
Second  printing  June,  1903 
Third  printing  September,  1908 
Fourth  printing  January,  1909 
Second  revised  edition  June,  1909 


PmNTCO 


Biomedical 
Library 


m 


This  Volume  is  Dedicated 


PROFESSOR    AUGUST    BIER 


The  Authors 


684025 


PREFACE  TO  THE  SECOND  EDITION 


The  fact  that  four  large  prmts  have  been  required  to 
supply  the  demand  for  the  book  since  it  was  launched  some 
ten  months  ago,  is  gratifying  proof  of  the  interest  that  Bier's 
hyperemic  treatment  has  aroused  among  the  English- 
speaking  profession. 

The  authors  are  convinced  that  the  physician  who  has 
given  the  treatment  a  fair  and  careful  test,  no  matter  in 
what  specialty,  and  has  thus  had  an  opportunity  of  per- 
sonally observing  the  often  remarkable  successes  that  can 
be  obtained,  will  be  so  much  pleased  that  he  will  be  eager  to 
give  the  method  a  permanent  place  in  his  therapeutic 
armamentarium.  He  will  have  learned  and  seen  with  his 
owTi  eyes  what  a  powerful  weapon  to  prevent  and  combat 
disease  we  possess  in  the  patient's  o^^Tl  blood.  The  fact 
that  the  method  requires  much  time  and  personal  care  will 
not"  be  a  deterrent  to  him.  He  will  consider  the  results 
obtainable,  and  these  will  goad  him  on  to  further  effort. 
And  this  is  the  way  Bier's  hyperemic  treatment  will  go 
on  gaining  disciples  until  there  will  be  none  left  to  withhold 
the  recognition  it  so  richly  deserves. 

The  authors  of  the  book  have  revised  the  text,  made  such 
additions  as  seemed  necessary,  and  have  tried  to  enhance 
the  value  of  the  book  by  interspersing  brief  histories  of 
interesting  cases.  They  have  also  furnished  an  index  to  the 
world  literature,  as  promised  in  the  first  edition.  While 
they  believe  it  is  fairly  thorough,  they  are  aware  that  it 

5 


6  PREFACE    TO   THE    SECOND    EDITION 

is  not  complete.  Perhaps  the  authors  whose  articles  have 
been  inadvertently  overlooked,  will  be  good  enough  to 
inform  either  of  the  writers  of  the  omission,  so  that  it  can 
be  made  good  in  a  third  edition. 

May  the  second  edition  of  our  book  on  Bier's  hyperemia 
treatment  make  as  many  friends  as  did  its  predecessor  and 
thus  help  to  swell  the  ranks  of  those  to  be  benefited  by 
this  gentle,  but  nevertheless  most  potent  therapeutic  agent. 

AViLLY  Meyer 
Victor  Schmieden 

New  York  and  Berlin 


PREFACE  TO  THE  FIRST  EDITION 


The  decision  to  write  and  publish  in  the  United  States 
a  manual  of  the  practical  uses  of  Bier's  hypereniic  treat- 
ment in  surgery,  medicine,  and  the  specialties  needs  no 
explanation. 

Bier's  teachings  are  of  such  far-reaching  importance 
and  great  practical  value,  that  there  can  be  no  doubt  that 
they  will  be  generally  introduced  in  the  United  States 
sooner  or  later. 

Nevertheless,  it  might  be  of  interest  to  mention  the  cir- 
cumstances that  impelled  the  authors  to  write  this  book : 

One  of  them  has  used  Bier's  hyperemic  treatment  in 
New  York  since  it  was  first  published,  fifteen  years  ago; 
he  was  probably  one  of  the  first  in  this  country  to  employ 
the  method.  The  results  he  obtained  have  been  so  remark- 
able from  the  outset  that  he  has  greeted  with  increasing 
interest  every  new  phase  in  its  evolution,  becoming  more 
and  more  convinced  of  the  value  of  the  treatment  as  an 
important  addition  to  our  therapeutic  resources.  Often 
he  has  presented  patients  thus  treated  in  clinics  and  before 
medical  meetings.  Of  late  he  has  begun  extending  its 
application  to  the  treatment  of  acute  inflammatory  troubles, 
alwaj'^s  closely  following  the  rules  laid  down  by  Bier.  He 
embodied  his  experiences  in  a  paper  read  in  the  Section  on 
Surgery  and  Anatomy  of  the  American  Medical  Association, 
at  its  Fifty-eighth  Annual  Session,  held  at  Atlantic  City, 
June,  1907  (Journal  Am.  Med.  Assoc,  August  17,  1907). 

7 


8  PREFACE    TO    THE    FIRST    EDITION' 

The  other  author  came  to  the  United  States  in  May, 
1907,  as  representative  of  his  chief,  Dr.  August  Bier, 
Professor  of  Surgery  at  the  University  of  Berhn,  to  read, 
on  invitation,  a  paper  on  "The  Treatment  of  Bone  and 
Joint  Tuberculosis  by  '  Stauungs-Hyperaemie '  "  before 
the  Surgical  Section  of  the  National  Association  for 
the  Study  and  Prevention  of  Tuberculosis,  at  its  third 
annual  meeting,  held  at  Washington  (New  York  Medical 
Record,  August  17,  1907).  Afterward  he  traveled  ex- 
tensively through  the  eastern  part  of  the  United  States, 
lecturing  on,  and  demonstrating,  the  procedure,  by  request, 
in  numerous  places,  and  everj^where  he  was  impressed 
with  the  great  interest  generally  shown  by  the  profession. 
No  less  was  he  impressed  with  the  extent  to  which  Bier's 
treatment  is  already  being  employed  in  America,  as  well 
as  the  unprejudiced  and  liberal  manner  in  which  the  new 
teachings  were  received  where  still  comparatively  unknown. 

But  one  and  the  same  great  need  so  often  recognized 
and  complained  of  by  others  became  apparent  to  him, 
wherever  he  went;  namely,  that  of  a  brief  and  compre- 
hensive manual  on  the  hyperemic  treatment,  that  would 
enable  not  only  the  surgeon  and  specialist  in  the  other 
branches  of  medicine,  but  also  the  general  practitioner 
to  become  familiar  with  the  method. 

It  is  in  order  to  fill  this  gap,  that  this  book  has  been 
written.  It  contains  in  a  nutshell  the  experiences  gathered 
at  Bier's  clinic,  where  the  hyperemic  treatment  had  its 
birth,  together  with  those  made  on  American  soil. 

Willy  Meyer 
Victor  Schmieden 

New  York  and  Berlin 


CONTENTS 


PAGE 

Introduction 17 


GENERAL  PART 

CHAPTER  I 

The  Advantages  of  the  Hyperemic  Treatment  Over 
Other  Methods 21 

CHAPTER  II 
Methods  of  Inducing  Hyperemia 23 

CHAPTER  III 

General  Rules  for  the  Application  of  Hyperemia  26 
Obstructive  hyperemia  by  Dieans  of  the  elastic  ban- 
dage    26 

Obstructive  hyperemia  by  means  of  suction  appa- 
ratus    44 

The  induction  of  hyperemia  by  means  of  hot  air.  .  .  64 

SPECIAL  PART 

The  Treatment  of  Special  Diseases  by  Means  of  Arti- 
ficial Hyperemia 78 

CHAPTER  IV 

Hyperemic  Treatment  in  Surgery 79 

Traumatisms 79 

Inflammations 84 

Acute  infections 84 

Furuncles  and  carbuncles 84 

Abscesses,    acute    lymphadenitis,    infected 
wounds,   acute   infectious   inflammations 

within  the  mouth  and  of  the  face 90 

Puerperal  mastitis 96 

9 


10  CONTENTS 

PAGE 

Acute    infectious    inflammation    of    joints 

(arthritis  gonorrhoeica) 101 

Felon  and  phlegmon  of  the  tendon-sheaths  105 

Acute  osteomyelitis 118 

Recurrent  osteomyelitis 121 

Erysipelas 121 

Obstructive  hyperemia  as  a  prophylactic 122 

Appendix — Compound  fractures 128 

Chronic  infections 131 

Tuberculosis 131 

Tuberculosis  of  spine,  ilio-sacral  joint  and 

of  the  OS  sacrum 145 

Tuberculosis  in  various  localities 151 

Syphilis 160 

Chronic  inflammations  not  due  to  specific  bac- 
teria     161 

Chronic  arthritis  (chronic  articular  rheuma- 
tism);     arthritis    deformans;      arthritis 

urica  (gout) 161 

Appendix — Joint  stiffness  following  inflam- 
mation    163 

Various   surgical   diseases   benefited   by   Bier's 

treatment 164 

Diseases  belonging  to  the  domain  of  ortho- 
pedic   surgery:     inflammatory    flat-foot 

and  scoliosis 164 

Varicose  veins;    ulcerations  of  the  leg. . . .    167 
Senile  and  diabetic  gangrene;  gangrene  due 

to  embolism  of  the  main  artery 168 

Burns 170 

Frost  bites 170 

Intraperitoneal  adhesions 170 

Tumors 170 

CHAPTER  V 
Hyperemic  Treatment  in  Medicine 172 

CHAPTER  VI 
Hyperemic  Treatment  in  Gynecology  and  Obstetrics  184 

CHAPTER  VII 
Hyperemic  Treatment  in   Genito-urinary  Surgery  188 

CHAPTER  VIII 
Hyperemic  Treatment  in  Otology 194 


CONTENTS  11 

CHAPTER  IX 
Hyperemic  Treatment  in  Ophthalmology 199 

CHAPTER  X 

Hyperemic  Treatment  ix  Rhixology,  Pharyngology, 
AXD  Laryxgology 202 

CHAPTER  XI 

Hyperemic    Treatmext    ix    Neurology,    Ixcludixg 
Psychiatry 206 

CHAPTER  XII 
Hyperemic  Treatmext  ix  Dermatology 210 


coxclusiox 211 

Literature  of  Bier's  Hyperemic  Treatment 217 

Index  to  Bibliography 263 

General  Index 269 


LIST  OF  ILLUSTRATIONS 

FIG.  PAGE 

1.  Application  of  Bier's  elastic  bandage  around  arm. .  .  28 

2.  Application  of  Bier's  elastic  bandage  around  arm. ...  29 

3.  Application  of  Bier's  elastic  bandage  around  arm. ...  30 

4.  Dressing  during  treatment 32 

5.  Technique  for  obstructive  hyperemia  at  shoulder-joint .  38 

6.  Elastic  neck-band 39 

7.  Rubber  bandage  used  for  neck-band 40 

8.  Neck-band  made  of  black  rubber 40 

9.  Application  of  elastic  bandage  for  obstructive  hyper- 

emia of  head 41 

10.  Obstructive  hyperemia  for  testicles 42 

11.  Rubber  tube  for  testicles 42 

12.  Rubber  tube  for  testicles 43 

13-16.  Suction  glasses 46 

17-20.  Suction  glasses 47 

21-22.  Suction  pumps 48 

23.  Suction  glass  for  puerperal  mastitis 48 

24.  Suction  glass  for  puerperal  mastitis 49 

25-29.  A^acuum  glasses 50 

30-32.  Vacuum  glasses 51 

33.  Patients  treated  with  suction  cups  for  suppuration 

and  fistulous  tuberculosis 53 

34.  Suction  apparatus  for  finger  (felon,  etc.) 54 

35.  Suction  apparatus  for  hand 55 

36.  Medium  position  for  moving  wrist  in  vacuum  glass.  .  56 

37.  Dorsal  flexion  of  wrist  produced  by  the  vacuum 56 

38.  Volar  flexion  of  hand 57 

39.  Strongest  volar  flexion 57 

40.  Passive  stretching  of  the  fingers 58 

41.  Fingers  pressed  into  flexion  by  vacuum 58 

42.  Foot-piece  in  place  without  supports 59 

43.  Cushion  under  heel  for  treatment  of  talipes  calcaneus  59 

44.  Movable  and  adaptable  support  under  the  fore  part 

of  the  foot  for  treatment  of  pes  equinus 60 

45.  Large  laterally  slanting  cushion  in  place 60 

46-48.  Apparatus  for  finger-stretching 61 

49.  Suction  apparatus  for  elbow-joint 62 

50.  Suction  apparatus  for  knee-joint 62 

51.  Suction  apparatus  for  knee-stretching 63 

52.  Contracted  knee  stretched  by  suction  apparatus.  ...  63 

53.  Hot-air  box,  open 65 

54.  Wooden  hot-air  box  for  hand 66 

55.  Hot-air  box  for  elbow. ...    67 

13 


14  LIST   OF   ILLUSTRATIONS 

FIG.  PAGE 

56.  Hot-air  box  for  shoulder 68 

57.  Hot-air  box  for  shoulder 69 

58.  Hot-air  chamber  for  foot 70 

59.  Hot-air  chamber  for  knee 71 

60.  Hot-air  chamber  for  whole  leg 72 

61.  Hot-air  chamber  for  both  hips 73 

62.  Hot-air  douche  for  trigeminal  neuralgia 74 

63.  Hot-air  douche  for  sciatica 75 

64.  Small  size  elastic  band  for  the  finger 80 

65.  Klapp's  suction  cup  in  case  of  carbuncle 87 

66.  67.  Furuncle  of  lips 89 

68.  Suction  glass  applied  to  breast 97 

69.  Suction  cup  applied  to  breast 98 

70.  Anatomy  of  palm  of  hand • 110 

71.  Klapp's  incisions  of  infected   sheath  of  the  flexor 

tendons  of  the  hand  and  forearm Ill 

72.  Incisions  in  case  of  suppuration  within  tendon-sheaths 

of  volar  flexors ;  .  113 

73.  Phlegmon  of  hand  and  forearm 115 

74.  Deep  and  large  soiled  wound  of  volar  aspect  of  forearm  123 

75.  Elastic  bandage  in  fistulous  tuberculosis  of  elbow.  136 

76.  Suction  glass  in  tuberculosis  of  elbow 137 

77.  Plaster-of-paris  support  in  tuberculosis  of  the  knee.  .  139 

78.  Same  as  Fig.  77  as  carried  out  by  instrument-maker  139 

79.  Combined  treatment  of  contracted  tuberculous  knee- 

joint 140 

80.  81.  Cured  tuberculosis  of  left  knee 141 

82.  Tuberculous  affection  of  metatarsus 142 

83.  Daily  scene  at  children's  ward 143 

84.  Local  hyperemia  in  tuberculosis  of  theos  sacrum. .  .   147 

85.  Suction  cup  in  use,  same  case  as  figure  84 148 

86.  Elastic  tube  in  position  in  double  tuberculous  epididy- 

mitis    154 

87.  88.  Tuberculous  epididymitis  treated  with  suction- 

glass  155 

89.  Apparatus  for  pes  varus 164 

90.  Hot-air  box  for  scoliotic  patients 166 

91.  Kuhn's  lung  suction  mask 176 

92.  Kuhn's  lung  suction  mask  in  position 178 

93.  Hot-air  box  treatment  of  lumbago 182 

94-96.  Suction  glasses  for  cervix  uteri 185 

97.  Suction  glass  for  pars  pendula  penis  in  gonorrhea. . .    188 

98.  Suction  apparatus  for  prostate 189 

99.  Suction  glass  for  sty 200 

100.  Suction  apparatus  for  nose 203 

101-103.  Suction  glasses  for  tonsils 204 


BIER'S 
HYPEREMIC   TREATMENT 


WILLY  MEYER-SCHMIEDEN 


BIER'S   HYPEREMIC   TREATMENT. 


INTRODUCTION. 

The  physician  who  intends  to  make  use  of  artificial 
hyperemia  must  first  have  a  clear  idea  as  to  what  he  wishes 
to  accomplish  with  it.  To  employ  artificial  hyperemia 
means  to  increase  the  quantity  of  blood  in  a  given  diseased 
part  of  the  body,  hoping  thereby  to  obtain  beneficial 
results. 

The  task  of  the  blood  is  to  circulate  through  all  the  differ- 
ent tissues  of  the  body,  with  few  exceptions,  and  to  main- 
tain therein  the  various  physiologic  functions. 

But  the  blood  current  accomplishes  this  not  only  under 
normal  conditions,  but  tries  to  adapt  itself  also  to  abnormal 
states.  As  soon  as  the  body  is  invaded  by  disease  or 
disturbing  external  influences,  requiring  an  increase  or 
decrease  of  the  blood  current,  the  circulator}'  conditions 
become  changed. 

Everyone  who  gives  this  matter  some  reflection,  must 
come  to  recognize  that  the  body  in  such  instances,  in  prop- 
erly regulating  the  blood  current,  does  a  definite,  deli- 
cate work,  thereby  often  preventing,  or  even  curing 
serious  disease. 

Physicians  must  learn  to  recognize  in  the  circulatory 
blood  one  of  the  most  powerful  factors  in  the  human  and 

2  17 


18  bier's  hyperemic  treatment. 

animal  system  in  bringing  about  the  so-called  "  spontaneous 
cures." 

To  explain,  a  burn  may  be  cited  as  an  example:  A  hot 
iron  is  brought  close  to  the  surface  of  the  body.  Immedi- 
ately the  skin  turns  red.  We  call  this  the  first  degree  of  a 
burn.  This  reddening  of  the  skin  represents,  according  to 
Bier,  the  body's  attempt  at  protecting  the  injured  part, 
the  accelerated  blood  current  cooling  off  the  heated  part 
and,  at  the  same  time,  furnishing  increased  nutrition  in  the 
hour  of  danger. 

With  the  cause  persisting,  the  redness  becomes  more 
and  more  marked,  while  the  sensitive  nerves,  through  the 
production  of  pain,  bring  the  immment  danger  to  the  atten- 
tion of  the  brain.  Soon  the  cooling  blood  current  proves 
insufficient.  A  large  accumulation  of  serum,  a  blister, 
developing  between  the  layers  of  the  skin,  is  furnished  by 
the  blood  as  a  further  protection  against  the  injurious 
effect  of  the  heat.  To  accomplish  this,  the  body  has  to 
give  up  the  external  layer  of  the  epidermis.  We  call  this 
appearance  of  a  blister  the  second  stage  of  a  burn. 

With  the  appearance  of  the  eschar,  the  body  throws  up 
the  gauntlet,  being  no  longer  able  to  successfully  employ 
the    curative    reactive    inflammation.     Necrosis    sets    in. 
This  is  the  third  stage  of  a  burn. 
Definition  of  Analogous  work  is  done  by  the  blood  current  in  infectious 

fltunmaUon.'^'  processes, — although  with  reduced  rapidity  in  the  con- 
spicuousness  of  the  various  phases, — when  bacterial 
toxins  take  the  place  of  the  red-hot  iron,  as  showTi,  for 
instance,  in  the  inflammatory  redness  and  the  edema  of  a 
furimcle,  a  phlegmon,  an  insect  bite,  etc.  We  have  the 
same  elemental  fight  of  the  system  against  an  invading 


INTRODUCTION.  19 

foe.  The  spontaneous  disappearance  of  an  inflammation 
means  no  less  and  no  more  than  the  victorious  fight  of  the 
increased  blood  current  against  the  bacteria. 

He  who  has  followed  this  train  of  thought  will  coincide 
with  Bier,  that  an  inflammation — from  the  physiologic 
point  of  view — does  not  in  itself  represent  a  diseased  condi- 
tion, but  is  a  phenomenon  indicating  the  body's  attempt 
to  resist  a  deleterious  invasion. 

To  increase  this  heneficent  inflammatory  hyperemia  result-  Aim  of  Bier's 

Hyperemic 
ing  from  the  fight  of  the  living  body  against  invasion,  is  the  Treatment. 

aim  of  Bier's  hyperemic  treatment. 

By  deduction  from  this  simple  reasoning  we  are  able 
to  discern  the  first  and  most  important  principle  under- 
lying Bier's  hyperemic  treatment,  namely: 

The  hlood  must  continue  to  circulate,  there  must  never  be  First  Principle 

Underlying  Hy- 

a  stasis  of  the  hlood.     This  point  is  of  such  paramount  peremic  Treat- 
importance  that  it  must  be  stated  ahead  of  and  apart  from 
the  rules  that  will  be  given  later  for  the  proper  applica- 
tion of  the  treatment. 

Bier's  teachings  are  of  equal  importance  in  explanation  Artificial  In- 

1-1  crease  of  the  In- 

of  mflammatory  processes,  as  they  are  m  the  treatment  flammation. 

of  the  same.     If  they  be  correct,  we  shall  have  to  part 

with  a  number  of  time-honored  views,  up  to  the  present 

time  accepted  as  pathologic  truths. 

Hitherto  it  was  considered  the  physician's  first  duty  to 
fight  every  kind  of  inflammation,  since  inflammations 
were  looked  upon  as  detrimental. 

Bier  teaches  just  the  opposite:  namely,  to  artificially 
increase  the  redness,  swelling  and  heat,  three  of  the  four 
cardinal  symptoms  of  acute  inflammation. 


20  bier's  hyperemic  treatment. 

Hence,  all  means  that  tend  to  subdue  an  inflammation 
are  to  be  discarded. 

To  cite  an  example:  According  to  Bier,  it  is  a  direct 
mistake  if  the  physician  orders  the  use  of  an  ice-bag  at 
the  time  of  a  beginning  inflammation.  By  so  doing  he 
resists  the  healthy  reaction  of  the  body;  he  suppresses 
the  salubrious  effect  of  the  inflammation  and  favors  the 
deleterious  influence  of  the  bacteria.  The  fact  that  the 
ice-bag  often  brings  comfort  to  the  patient  and  reduces 
the  pain,  at  least  temporarily,  does  not  invalidate  the 
truth  of  the  above  dictum  any  more  than  the  fact  that  an 
ice-cold  drink  momentarily  comforts  a  feverish  patient. 

The  same  rule  obtains  here  as  is  generally  applied  in 
the  case  of  infectious  disease.  There  are  very  few  physi- 
cians to-day  who  would  attempt  to  reduce  the  fever  in  such 
cases.  We  have  learned  to  look  upon  this  fever  as  one  of 
the  weapons  of  the  organism  in  its  fight  against  the  intruder. 

It  would  lead  too  far,  to  consider  here  the  many  theories 
advanced  in  explanation  of  the  effect  of  hyperemia.  This 
book  is  to  deal  with  the  practical  application  of  the  latter. 
Suffice  it  to  say,  that  the  artificial  increase  of  all  the  symp- 
toms and  attributes  of  the  complicated  phenomenon, 
which  we  call  inflammation,  evidently  is  necessary,  in 
order  to  succeed  in  conquering  the  acute  inflammation. 

The  practical  results  obtained  with  the  hyperemic  treat- 
ment have  proved  beyond  the  shadow  of  a  doubt  the  abso- 
lute correctness  of  the  theories  advanced  bv  Bier. 


General  Part. 


CHAPTER  L 

THE  ADVANTAGES  OF  THE  HYPEREMIC  TREAT- 
MENT OVER  OTHER  METHODS. 

These  are  the  following: 

1.  Suppression  of  the  infection. 

2.  Avoidance  of  suppuration  in  many  cases. 

3.  The  possibility  of  using  small  instead  of  large  inci- 
sions in  cases  in  which  suppuration  has  already  set  in. 

4.  Hastening  the  course  of  the  pathologic  process. 

5.  Favoring  absorption. 

6.  Diminution  of  pain. 

7.  Its  wide  field  of  usefulness. 

Since   it   has   been   demonstrated,    that   by   increasing  Suppression  of 
the   inflammatory   symptoms   a   beginning   infection   can 
be  made  to  subside,  w^e  ought  to  more  generally  practise 
abortive   treatment   of    incipient    troubles   of    this  kind; 
for  instance,  of  incipient  phlegmons  or  furuncles. 

While   it   is   not   possible   to   suppress   every   infection  Avoidance  of 
before  pus  is  formed,  there  is  no  question  that  by  means  many  cases, 
of  artificial   hyperemia    suppuration    can    be    avoided   in 
a  larger  percentage  of  cases  than  by   any  of    the   other 
therapeutic  measures  at  our  disposal. 

21 


22 


BIER  S   HYPEREMIC   TREATMENT. 


The  Possibility 
of  Using  Small 
Instead  of  Large 
Incisions  in  the 
Cases  in  which 
Suppuration 
has  Already  Set 


Hastening  the 
Course  of  the 
Pathologic  Pro- 


Favoring  Ab- 
sorption. 


Diminution  of 
Pain. 


Wide  Field  of 
Usefulness. 


In  cases  in  which  suppuration  is  unavoidable  even  with 
the  aid  of  artificial  hyperemia,  owing  to  the  intensity  of 
the  infection,  Bier's  treatment  enables  us  to  accomplish 
with  small  incisions,  what  formerly  could  be  achieved  with 
large  ones  only.  This  has  been  shown  by  manifold  practi- 
cal experiences.    The  advantage  is  obvious. 

The  increased  supply  of  blood  hastens  markedly  the 
course  of  a  suppuration,  inasmuch  as  it  favors  the  rapid 
development  or  demarcation  and  separation  of  necrosed 
portions  in  soft  tissues  as  well  as  in  bones  (rapid  formation 
of  sequestra). 

The  hyperemic  treatment  has  been  found  most  useful 
in  that  it  favors  the  absorption  of  exudates  and  pathologic 
tissue  changes  of  various  kinds. 

There  is  no  other  method  that  is  superior  to  hyperemic 
treatment  in  point  of  gentleness  and  painlessness  of  appli- 
cation as  well  as  tendency  to  reduce  pain. 

Bier's  treatment  can  be  employed  to  advantage  in  a 
large  variety  of  acute  and  chronic  inflammatory  diseases. 
It  is  applicable  and  has  proven  useful  in  surgery,  medicine, 
and  the  specialties  alike. 


CHAPTER  II. 

METHODS  OF  INDUCING  HYPEREMIA. 

There  are  three  methods  by  which  hyperemia  may  be 
produced : 

1.  By  means  of  an  elastic  bandage  or  band; 

2.  By  means  of  cupping  glasses; 

3.  By  means  of  hot  air. 

1  and  2  produce  a  passive  or  venous  hyperemia,  3  an 

active  or  arterial  hyperemia. 

Retarding  the  return  of  the  blood  to  the  heart  by  com-  The  Elastic 
,  .  ,  .  .  ~  Bandage, 

pressmg  the  vems  at  the  most  convenient  place  between 

the  focus  of  inflammation  and  the  heart  with  the  help 

of  an  elastic  bandage  or  band  represents  the  oldest  and 

typical  method  of  producing  artificial  hyperemia. 

The  Germans  call  this  "  Stauungs-hyperaemie,"  a  term 
describing  cause  as  well  as  effect. 

A  word,  covering  the  principle  of  the  procedure  as  this 
does,  is  not  to  be  found  in  the  English  language.  "Ob- 
structive hyperemia"  might  be  suggested,  but  the  word 
represents  the  cause  only,  not  the  effect.  "Stasis  hyper- 
emia" would  be  an  absolutely  false  interpretation  of  the 
process.  What  pathologists  call  a  stasis  is  exactly  what 
must  be  prevented  in  applying  artificial  hyperemia. 

"Congestive,"  "induced,"  "dammed,"  "obstructed," 
"impeded,"  "artificial-active"  and  "artificial-passive" 
or  "artificial-arterial"  and  " artificial- venous "  hyperemia 
also  express  but  poorly  the  mechanical  cause  and  physio- 

23 


24  bier's  hyperemic  treatment. 

logic  effect  of  the  procedure.  We  think,  therefore,  that 
it  would  probably  be  best  to  take  over  bodily  the  word 
"  Stauungs-hyperaemie  "  into  the  English  language.  Every 
physician,  here  and  abroad,  would  then  at  once  under- 
stand which  kind  of  artificial  hyperemia  was  referred  to; 
viz.,  the  venous  one,  which  can  be  produced  either  by  the 
elastic  bandage  or  by  suction  glasses.  The  arterial  hyper- 
emia, brought  on  by  hot  air,  is,  of  course,  not  a  "Stauungs- 
hyperaemie. "  It  would  be  best  called :"  hot-air-hyperemia. " 

Inasmuch  as  the  word  "Stauungs-hj^peraemie"  has  not 
as  yet  been  adopted,  the  term  " obstructive  hyperemia" 
will  be  used  in  place  of  it  in  the  following  pages. 
•  This  obstructive  h^-peremia,  when  produced  by  means 
of  the  elastic  bandage,  can  be  employed  only  in  diseases 
of  the  head,  scrotum  and  testicles,  and  the  extremities. 
That  is  to  say,  in  the  case  of  the  former  the  compressing 
bandage  is  applied  around  the  neck  or  the  base  of  the 
scrotum;  in  the  latter,  around  the  extremity  above  the 
inflammatory  focus. 

In  the  upper  extremities  it  can  be  used  for  affections 
from  the  shoulder-joint  (inclusive)  down  to  the  finger  tips. 
As  to  the  lower  extremities,  while  all  portions  below  the 
hip  can  be  readily  made  to  profit  by  the  method,  it  has 
been  found  impossible  so  far,  for  anatomic  reasons,  to 
apply  the  treatment  to  the  hip-joint  itself. 
Cupping  Where  hyperemia  by  means  of  elastic  compression  is 

not  feasible,  it  can  be  produced  by  suction.  This  method 
is  used  upon  the  breast,  back,  spine,  pelvis,  and  the  surface 
of  the  whole  body  whenever  a  localized  acute  infection  or 
an  open  wound  (sinus,  granulation,  etc.)  is  present.     For 


METHODS    OF    IXDUCIXG    HYPEKEMIA.  25 

this  purpose  cupping  glasses  of  various  size  and  shape  are 
employed. 

As  has  been  said  already,  the  hyperemia  produced  by 
the  cupping  glasses  is  also  principally  an  obstructive 
hyperemia. 

Hot  air  is  generated  in  wooden  or  metal  boxes  especially  Hot  Air. 
constructed  to  suit  the  respective  case.     This  represents 
an  arterial  hyperemia. 


CHAPTER  III. 

GENERAL  RULES  FOR  THE  APPLICATION  OF 
HYPEREMIA. 

I.  OBSTRUCTIVE  HYPEREMIA  BY  MEANS  OF  THE  ELASTIC 
BANDAGE. 

Elastic  Ban-  As  has  been  said  before,  this  is  the  older  and  principal 

dage. 

•  method. 

This  obstructive  hyperemia  is  produced  by  means  of  a 
soft  rubber  bandage,  same  as  is  used  for  the  production 
of  artificial  anemia  in  the  case  of  bloodless  operations  on 
the  extremities. 

In  slightly  obstructing  the  return  of  the  blood  from 
the  extremity  to  the  heart  with  the  aid  of  such  a  soft 
rubber  bandage,  the  principal  point  to  be  observed  is 
that  the  circulation  be  never  entirely  interrupted.  What 
must  be  our  aim  is  to  retard  the  return  of  the  blood  from 
the  extremity  under  treatment,  in  this  way  increasing 
the  quantity  of  blood  normally  contained  therein,  but 
in  no  way  to  interfere  with  the  influx  of  the  blood  through 
the  artery.  The  bandage  must  be  applied  firmly  enough 
to  slightly  constrict  the  lumen  of  the  thin-walled  veins, 
but  not  sufficiently  so  to  compress  the  more  resistant 
walls  of  the  arteries. 

One  must  at  all  times  be  able  to  feel  the  pulse  below  the 
place  surrounded  by  the  elastic  bandage. 

26 


OBSTRUCTIVE    HYPEREMIA    BY    ELASTIC    BANDAGE.        27 

This  rule  cannot  be  emphasized  too  strongly.  Nearly 
all  beginners  are  apt  to  apply  the  bandage  too  tightly. 

Yet,  it  is  not  difficult  to  find  the  proper  measure  of 
compression.  The  patient's  own  feelings  are  the  best 
guide,  for  the  degree  of  obstructive  hyperemia  is  a  correct 
one,  if  the  patient  is  not  in  the  least  annoyed  by  the  bandage 
applied.  As  soon  as  the  latter  unduly  constricts,  pares- 
thesias will  be  noticed  in  the  part  subjected  to  hyperemia; 
then  pain  will  set  in.  Objectively,  this  mistake  can  be 
recognized  by  the  too  rapid  turgescence  of  the  subcu- 
taneous veins;  furthermore,  the  extremity  will  assume  a 
bluish-red  appearance;  a  little  later  there  will  be  red 
blotches  and  small  subcutaneous  hemorrhages  will  become 
noticeable.  If  the  constriction  is  continued,  the  part 
becomes  cyanotic  in  appearance  and  the  pulse  disappears. 
As  soon  as  any  of  these  symptoms  become  evident,  the 
bandage  should  be  removed,  and  less  tightly  reapplied  a 
little  later. 

Let  it  be  said  again,  that  there  must  be  no  increase  of 
pain,  while  the  bandage  is  in  place.  The  patient  should 
be  requested  to  inform  the  physician  as  soon  as  pain  sets 
in  or  already  present  pain  becomes  worse.  The  bandage 
then  should  be  changed  and  put  on  more  loosely. 

The  technique  is  correct,  if  there  is  absolutely  no  increase 
of  pain  and  if  there  is  visible  hyperemia  of  the  part  subjected 
to  the  treatment. 

On  the  other  hand,  the  elastic  bandage  must  not  be 
applied  too  loosely.  This  would  produce  a  mere  obstruc- 
tion to  the  return  of  the  lymph,  the  accumulation  of  which 
alone  is  not  wanted.  The  portion  distal  to  the  bandage 
must  appear  bluish  or  bluish-red — never  white. 


28 


BIER  S    HYPEREMIC    TREATMENT. 


The  freedom  from  pain  must  extend  also  to  the  area 
surrounded  by  the  bandage.  Bier  employs  a  soft  rubber 
bandage,  2h  inches  wide,  which  he  winds  around  the  limb 
about  six  to  eight  times,  one  layer  overlapping  the  other 


Fig.  1. — Demonstrating  the  application  of  Bier's  elastic  bandage 
around  the  arm.  The  flannel  bandage  is  used  for  padding.  This  is 
rarely  required.  The  bandage  is  2^  inches  wide  and  is  applied  so 
as  to  have  one  layer  overlap  the  other  by  ^  inch.  The  end  is  fastened 
with  a  pin,  but  can  just  as  well  be  tucked  under  (Fig.  2)  or  tied  with 
tapes,  which  are  stitched  on  to  the  end  of  the  bandage  (Fig.  3). 
The  distal  part  of  the  extremity  shows  a  distinct  obstructive  hyperemia. 
The  patient  suffers  no  pain  and  no  annoyance. 


by  about  one-half  inch.  In  this  manner  the  pressure  is 
evenly  distributed  over  a  comparatively  wide  area.  The 
end  may  be  fastened  with  a  safety-pin  (Fig.  1)  or  tucked 


OBSTRUCTIVE    HYPEREMIA    BY    ELASTIC    BANDAGE. 


29 


under  (Fig.  2)  or  tied  with  tapes,  which  are  stitched  on 
to  the  bandage  (Fig.  3).* 

Only  in  cases  which  require  the  bandage  to  remain  in 


P'ig.  2. — This  illustration  shows  the  application  of  the  elastic  bandage 
around  the  arm,  with  its  end  tucked  under. 


place  for  longer  periods,  say  twenty  to  twenty-two  hours 
per  day,  will  it  be  necessary  or  desirable  to  first  apply  a 

*  Rubber  bandages  are  sometimes  very  slippery,  causing  the  turns 
to  become  loosened,  although  the  end  is  properly  tied  with  the  tapes. 
In  such  a  case  it  is  advisable  to  secure  the  end  Ijesides  with  two  strips 
of  adhesive  plaster,  or  moisten  the  lower  surface  of  the  last  turn  with 
water. 


30 


BIER  S    HYPEREMIC   TREATMENT. 


soft  flannel  bandage  underneath  the  rubber  bandage, 
in  order  to  avoid  pressure  necrosis.  (Fig.  1.)  Frequently 
changing  the  location  of  the  bandage  up  and  down  the 


Fig.  3. — Shows  elastic  bandage  in  place  around  the  arm,  its  ends 
tied  with  tapes  which  are  attached  to  the  bandage.  This  is  the  style 
of  bandage  usually  found  upon  the  market.  If  the  bandage  is  to  re- 
main on  for  a  number  of  hours,  it  is  advisable  to  apply  a  strip  of  ad- 
hesive plaster,  to  guard  against  the  tapes  becoming  undone.  Note  the 
engorgement  of  the  subcutaneous  veins  of  the  forearm  in  Figs.  1  to  3, 
showing  the  effect  it  is  desired  to  produce  by  the  bandage. 


extremity,  and  treating  the  skin  with  alcohol  rubs,  will 
also  be  helpful  in  patients  with  tender  skin. 


OBSTRUCTIVE    HYPEREMIA    BY    ELASTIC    BAXDAGE.        31 

With  the  bandage  in  place,  the  chstal  part  of  the  extrem- 
ity must  feel  warm,  not  cold. 

It  is  not  easy  to  produce  a  warm  or  hot  obstructive 
hyperemia  in  a  healthy  limh;  nor  does  one  ahvays  succeed 
in  increasing  the  temperature  of  a  tuberculous  joint  in 
this  manner.  But  every  focus  of  acute  injiammation 
subjected  to  obstructive  hyperemia  will  quickly  show 
increased  warmth.  First  we  notice  a  marked  redness, 
then  heat  and  a  swelling.  On  seeing  the  swelling  increase, 
the  practitioner  often  becomes  frightened,  but  there  is  no 
reason  for  alarm.  According  to  Bier,  this  phenomenon 
is  to  be  looked  upon  as  a  welcome,  salubrious  reaction. 

The  first  effect  observed  in  conjunction  with  this  arti- 
ficially exaggerated  inflammation,  is  the  diminution  of 
pain,  becoming  more  and  more  noticeable  with  the  appear- 
ance of  the  edema. 

This  disappearance  of  pain  is  best  demonstrated  in 
acutely  inflamed  joints;  e.  g.,  a  gonorrheal  joint.  The  best 
proof  for  a  perfect  technique  is  our  ability  to  make  passive 
motions  with  such  joints,  about  one  hour  after  the  appli- 
cation, without  creating  pain. 

The  elastic  bandage  must  always  be  placed  upon  a 
healthy  area,  proximally  to  the  seat  of  the  disease.  It 
should  never  touch  the  latter. 

For  affections  of  the  upper  and  lower  extremities  it  has 
been  made  a  rule  to  always  apply  the  bandage  around  the 
arm  or  thigh  even  though  hand  or  foot  be  the  seat  of  the 
disease.  It  is  of  no  consequence  that  in  such  cases  the 
elbow  or  knee-joint  are  incidentally  also  subjected  to 
hyperemia.  It  never  causes  an  exudation  into  the  healthy 
joint,  not  does  it  ever  produce  varicose  veins.     The  reason 


32 


BIER  S    HYPEREMIC   TREATMENT. 


for  SO  doing  is  that  in  forearm  and  leg  the  interosseal 
veins  are  not  sufficiently  affected  by  the  elastic  compres- 
sion, and,  hence,  the  hyperemia  would  be  less  reliable. 


Fig.  4. — Shows  a  plain  towel  dressing,  as  it  is  best  applied  during 
the  treatment  of,  for  instance,  a  phlegmon  of  the  hand.  The  wounds 
are  loosely  covered  with  aseptic  gauze;  two  safety-pins  fasten  the 
towel,  which  holds  the  gauze  in  place  without  exerting  pressure.  Every 
dressing  which  in  any  way  compresses  the  diseased  parts  is  harmful, 
as  it  interferes  with  the  appearance  of  a  pronounced  hyperemia. 


Dressings   dur-      All  dressings  ought  to  he  removed  while  the  compressing 

ing  Obstructive     ,.,,..,.  ,  ,i  , 

Hyperemia.        elastic  bandage  is  m  place,  m  order  to  allow  the  respective 
part  to  properly  swell  and  become  hyperemic.     Wounds 


OBSTRUCTIVE    HYPEREMIA    BY    ELASTIC    BANDAGE.        33 

or  sinuses  are  covered  with  sterile  gauze  which  is  kept  in 

place  by  a  towel,  loosely  wound  around  the  same  and 

fastened  by  means  of  a  few   safety-pins.     The  extremity 

rests  upon  the  bed  or  a  table  or  the  patient's  lap  during 

the  application  of  the  bandage.     (See  Fig.  4.) 

If,   in  cases  of  chronic  diseases  a  distinct   hyperemia  Means  of 

does  not  set  in,  it  is  advisable  to  place  the  part   in  a  structive"  Hy- 

bath  as  hot  as  the  patient  can  stand  it,  for  about  ten  P^^^"^^^* 

minutes.     This  will  cause  the  extremity  to  ■  turn  bright 

red,  after  which  the  l^andage  is  applied  as  described  above. 

Every  obstructive  hyperemia  that  is  continued  for  several  Edema;    In- 
termission   of 
hours  produces  edema.  the   Obstructive 

This  edema  has  to  be  kept  wdthin  proper  limits.     The  mia.., 

physician  or  nurse  must  see  to  it  that  it  disappears  or  at 
least  becomes  greatly  reduced  after  the  removal  of  the 
bandage.  Of  course,  it  will  reappear  v\'ith  the  subsequent 
renewal  of  the  treatment. 

During  the  intermissions,  following  the  application  of 
the  elastic  bandage  for  short  periods,  say  from  two  to  four 
hours  each  day,  this  artificial  edema  always  becomes 
absorbed. 

However,  in  cases  requiring  a  long-continued  hyperemia, 
viz.,  twenty  to  twenty-two  hours  out  of  every  twenty-four 
hours,  in  which,  therefore,  the  time  for  the  absorption  of 
the  edema  is  rather  short  (being  reduced  to  two  to  four 
hours),  the  extremity  should  be  raised  on  pillows  or  by 
means  of  a  suspension  splint  during  the  intermission  period. 

In  acutely  infected  cases  the  rapid  absorption  of  this 
inflammatory  edema  is  often  followed  by  some  rise  of 
temperature;   this,  however,  is  of  short  duration  only. 

After  the  swelling  has  gone  down  and  before  reapplying 
3 


34 


BIERS    HYPEREMIC    TREATMENT. 


Abscesses. 


Treatment  of 
Abscesses. 


the  bandage,  careful  examination  should  be  made  to  see 
if  any  improvement  has  set  in  or  perhaps  pus  has  collected, 
even  though  such  an  examination  may  not  always  be  very 
reliable  on  account  of  the  edema  present. 

The  question  now  arises  as  to  how  the  physician  should 
proceed  in  the  event  of  abscess  formation  during  obstruc- 
tive hyperemia,  or  when  he  is  called  upon  to  treat  by  this 
method  inflammatory  conditions,  that  are  already  com- 
plicated with  abscess  formation. 

The  idea  which  may  arise  in  the  minds  of  those  who  have 
studied  Bier's  treatment  only  superficially — namely,  that 
abscesses  now  no  longer  need  to  be  incised — is  absolutely 
erroneous.  Such  an  omission  would  be  fraught  with 
danger  to  the  patient. 

It,  therefore,  should  be  stated  as  one  of  the  most  impor- 
tant rules  that  also  under  hyperemic  treatment  every  abscess 
has  to  be  opened.  Every  bit  of  pus  should  be  evacuated. 
The  knife  takes  care  of  the  pus;  hyperemic  treatment 
fights  the  infection. 

While  there  may  be  no  need  of  particular  hurry  in  the 
event  of  a  cold  abscess,  it  is  essential  that,  in  the  case  of 
acute  inflammations,  an  abscess  should  be  opened  without 
delay. 

Thus,  Bier's  treatment  does  not  mean  any  primary 
change  in  dealing  with  an  abscess.  No  matter  whether 
the  pus  has  collected  in  the  subcutaneous  tissue,  or  between 
the  muscles,  in  sheaths  of  tendons  or  within  the  bones,  in 
joints  or  behind  the  drum  membrane,  always  the  same 
dictum  holds  good :  Evaluate  the  pus. 

In  considering  the  different  affections  we  shall  see, 
however,  that,  with  the  help  of  the  hyperemic  treatment, 


OBSTRUCTIVE    HYPEREMIA    BY    ELASTIC    BANDAGE.         35 

the  large  incisions  into  the  abscess  cavity,  heretofore 
practised,  can  be  dispensed  with;  often  mere  punctures 
will  suffice.  These  punctures  can  be  made  without  general 
anesthesia  and  naturally  heal  much  more  rapidly  than 
large  incised  wounds;  furthermore,  there  is  no  need  of  the 
painful  tamponade  in  the  course  of  the  after-treatment, 
and  there  is  no  extensive  scar  formation. 

Experience    has   shown  that  acute  infectious  processes  The  Duration 
require  prolonged  application  of  the  hyperemic  treatment,  of  Obstructive 
from  twenty  to  twenty-two  hours  per  day.     In  chronic     yP^"^^"^^^- 
affections,  especially  those  of  tuberculous  origin,  shorter 
sittings,  say  two  to  four  hours  a  day,  have  been  found 
sufficient. 

More  definite  directions  are  given  later  on  in  the  chapters 

dealing  with  ''Special  Diseases."     It  is  there  also  stated, 

when  it  is  advisable  to  combine  obstructive  hyperemia 

with  other  methods,  in  order  to  procure  the  highest  feasible 

degree  of  hyperemia. 

In  order  to  become  familiar  with  the  hyperemic  treat-  Who  is  to  Ap- 
,  ,       .   .  1        ,  1  ^  ply   the   Elastic 

ment,  the  physician  should  at  first  apply  the  bandages  Bandage? 
himself.  Later,  he  may  train,  in  chronic  cases  at  least, 
nurses  or  relatives  or  even  the  patient  himself  to  do  this, 
but  he  must  never  cease  to  carefully  supervise  the  treat- 
ment, otherwise  mistakes  or  irregularities  in  the  technique 
may  occur  which  would  mar  the  result. 

It  is  most  gratifying  to  note  the  real  pleasure  displayed 
by  intelligent  patients  as  they  perceive  the  gradual  improve- 
ment that  occurs  under  the  application  of  this  gentle  and 
painless  treatment,  which  often  renders  unnecessary  muti- 
lating operations  that  otherwise  would  have  been  unavoid- 
able. 


36  bier's  hyperemic  treatment. 

In  view  of  the  fact  that  the  subjective  symptom  of  pain 
is  the  most  important  guide  to  the  proper  technique,  it 
is  really  a  good  plan  in  chronic  inflammations  and  tuber- 
culous affections  to  allow  intelligent  patients  to  learn 
how  to  apply  the  bandage  themselves.  However,  when 
it  comes  to  acute  processes,  the  physician  must  invariably 
carry  out  the  treatment  himself. 

The  technique  above  described  refers  to  the  treatment 
of  diseases  of  the  extremities. 

It  is  to  be  regretted  that,  for  anatomic  reasons,  the  hip- 
joint  cannot  thus  far  profit  by  Bier's  discovery.  But  we 
have  no  doubt  that  some  day  ways  and  means  will  be 
found  to  extend  the  method  also  to  this  joint.* 

*  A  few  months  ago  a  letter  was  received  from  a  colleague,  in  which 
he  proposed,  in  order  to  produce  a  hyperemia,  say  of  the  right  hip>-joint, 
to  apply  an  Esmarch  bandage  completely  around  the  upper  extremities 
and  the  left  lower  limb  and  on  the  right  to  within  one  to  three  inches  of 
the  trochanter  major.  By  then  placing  the  patient  in  a  standing  or 
a  semiprone  posture  he  expects  to  produce  the  desired  hyperemia. 
But  this  would,  at  best,  but  make  a  slight  arterial  hyjjeremia,  which  could 
be  more  easily  and  more  powerfully  produced  with  the  help  of  hot  air. 
What  is  needed,  in  acute  and  chronic  (tuberculous)  inflammations  is  an 
obstructive,  a  venous  hyf)eremia.     And  here  lies  the  difficulty. 

Obstructive  hyperemia  by  means  of  a  tourniquet  presenting  an  infla- 
table pad,  over  the  large  abdominal  vessels,  does  not  seem  unpractical. 
If  applied  over  the  abdomen  in  order  to  obstruct  the  inferior  vena  cava, 
it  would,  of  course,  incidentally  compress  the  aorta.  Still  the  pressure 
upon  this  large  vessel  would  not  be  great  enough  to  prevent  a  sufficient 
amount  of  blood  from  passing  to  the  lower  part  of  the  body,  while  its 
return  would  be  duly  impeded.  In  ascertaining  the  pulse  in  the  vessels 
of  the  lower  extremities  and  by  observing  the  color  of  the  skin  of  the 
same,  the  proper  degree  of  obstruction  could  always  be  nicely  gauged. 
Of  course,  the  entire  lower  half  of  the  body  would  thus  be  placed  under 
hyperemia,  but  this  would  do  no  harm  as  shown  by  the  experience  had 
with  joints  of  the  extremities.  It  remains  to  be  shown  by  clinical 
observation,  whether  a  procedure,  like  the  one  just  proposed,  would 
prove  useful,  especially  whether  a  patient  be  able  to  stand  a  prolonged 
compression  of  this  kind. 

Another  possible  solution  of  the  question  might  be  found  in  large 


OBSTRUCTIVE    HYPEREMIA    BY    ELASTIC    BANDAGE.        37 

The  shoulder  can  be  made  hyperemic  by  means  of  the  Shoulder  Artic- 
ulation, 
following  special  technique :  A  compress  of  gauze  or  other 

suitable  material  is  folded  and  tied  loosely  around  the 
patient's  neck.  (Fig.  5.)  Through  its  loop  a  piece  of 
strong  rubber  tubing  is  pushed  and  conducted  under- 
neath the  axilla  around  the  shoulder.  Then  the  tubing  is 
clamped  or  tied  on  top  of  the  shoulder,  more  or  less  firmly, 
according  to  the  degree  of  constriction  desired.  There- 
upon a  piece  of  bandage  is  tied  on  to  the  rubber  tubing, 
one  in  front,  another  behind,  the  two  ends  being  joined 
in  the  opposite  axillary  cavity. 

This  latter  manceuver  pulls  the  rubber  ring  well  over 
to  the  sternum  and  spine,  relieving  the  joint  from  pressure 
and  at  the  same  time  placing  it  under  obstructive  hyper- 
emia. A  glance  at  Fig.  5  will  explain  the  application  of 
the  tube. 

It  is  plain  that  the  treatment  needs  more  care  and  atten- 
tion here  than  elsewhere,  principally  for  the  reason  that 
the  elastic  pressure  is  exerted  always  upon  exactly  the 
same  spot.  The  physician,  therefore,  must  be  well  on  his 
guard  to  avoid  pressure  necrosis,  as  this  would  render  the 
continuation  of  the  treatment  impossible. 

Decubitus  can  be  obviated  by  padding  the  tube  with 
cotton  and  frequent  interruption  of  the  application. 

In  order  to  simplify  matters  a  ready-made,  padded 
rubber  ring  with  attached  straps  has  been  recommended 

glass  apparatus,  of  the  shape  of  tights,  including  the  entire  pelvis, 
with  one  rubber  cuff  around  each  thigh  and  another,  larger  cuff  or  belt 
around  the  abdomen,  being  adjusted  by  means  of  straps  and  buckles. 
Here,  too,  all  the  pelvic  organs  would  participate  in  the  hyperemia. 

Such  experiments  would,  of  course,  present  considerable  difficulty 
owing  to  the  expense  that  would  be  connected  with  the  construction 
of  the  proper  glass  apparatus. 


38 


bier's  hyperemic  treatment. 


for  this  purpose.  Bier  himself  favors  the  method  above 
described,  as  it  can  be  readily  improvised  by  any  one  and 
permits  of  better  regulation  of  the  degree  of  hyperemia. 


Fig.  5. — Technique  employed  for  the  production  of  obstructive 
hyperemia  at  the  shoulder-joint.  The  folded  piece  of  cloth  is  placed 
loosely  around  the  neck.  A  piece  of  stout  rubber  tubing,  under  the 
required  tension,  is  fastened  on  top  of  the  shoulder.  Two  pieces  of 
bandage  are  attached  to  the  rubber  tubing  in  front  and  behind  and  tied 
in  the  axilla  of  the  healthy  side,  pulling  the  ring  thus  formed  well  over 
toward  the  median  line. 


Obstructive 
Hyperemia  of 
the  Head. 


Next  to  the  extremities,  the  head  is  most  amenable  to 
obstructive  hyperemia.  A  strip  of  garter  elastic  about 
three-fourths  of  an  inch  wide,  with  a  hook  at  one  end 
and  a  number  of  eyes  on  the  other,  to  allow  for  different 


OBSTRUCTIVE  HYPEREMIA  BY  ELASTIC  XECK-BAXD.       39 

degrees  of  compression,  best  answers  the  purpose.  (Fig. 
6.)  If  such  elastic  be  not  on  hand,  a  piece  of  black  rubber 
bandage,  the  last  tour  or  layer  fastened  with  a  few  short 
straps  of  adhesive  plaster  (Fig.  7),  or  a  narrow  band, 
made  from  a  rubber  bandage,  with  a  button  at  one  end 
and  a  number  of  buttonholes  at  the  other  (Fig.  8),  will  be 
just  as  efficient. 

This  band  is  applied  around  the  neck  below  the  larynx; 
its  tension  has  to  be  regulated  according  to  the  need  of 
the  case. 

Here,  too,  it  is  of  utmost  importance  not  to  apply  the 


Fig.  6. — Elastic  neck-band  made  of  elastic  webbing.  The  bandage 
is  placed  below  the  larynx  and  can  be  worn,  without  showing,  under- 
neath a  high  collar. 

band  too  firmly.  It  must  never  strangulate.  The  patient 
himself  must  be  the  judge;  he  is  to  promptly  report  any 
annoyance.  The  object  of  the  treatment  is  to  increase 
the  quantity  of  blood  in  the  head,  but  the  hyperemia 
must  not  interfere  with  the  patient's  ability  to  sleep,  eat, 
and  drink. 

In  order  to  increase  the  obstruction,  a  piece  of  soft 
felt  may  be  slipped  under  the  bandage  at  the  site  of  the 
jugular  veins.     (Fig.  9.) 

Special  care  must  be  exercised  in  the  case  of  patients 
suffering  from  arterio-sclerosis.     It  should,  however,   be 


40 


BIER  S    HYPEREMIC    TREATMENT. 


Fig.  7. — Piece  of  rubber  bandage,  used  for  a  neck-band.  End 
fastened  with  two  strips  of  adhesive  plaster.  This  is  used  only  in 
cases  of  emergency,  inasmuch  as  the  bandage  cannot  well  be  placed 
below  the  larynx. 


Fig.  8. — Neck-band  made  of  black  rubber.  One  end  carries  a  but- 
ton, the  other  has  button-holes.  This  bandage  affords  greater  com- 
fort to  the  patient,  but  is  not  as  easily  made  as  the  one  shown  by  Fig.  6. 


OBSTRUCTIVE  HYPEREMIA  BY  ELASTIC  XECK-BAXD.       41 

emphasized,  that,  as  a  general  thing,  it  is  entirely  per- 
missible to  produce  a  distinct  edema  when  treating  acute 
inflammatory  processes  of  the  head,  same  as  is  done  in 
case  of  the  extremities. 


Fig.  9. — This  figure  shows  the  application  of  the  elastic  bandage 
for  the  production  of  obstructive  hyperemia  of  the  head.  To  increase 
the  hyperemia  a  piece  of  soft  felt  is  placed  over  the  large  venous  trunks 
of  the  neck  beneath  the  bandage. 


The  technique  of  obstructive  hyperemia  in  diseases  of  Obstructive 

Hyperemia    of 
the  testicles  is  simple.     Some  rubber  drainage  tubing,  best  the  Testicles. 

of  medium  size  (about  20  to  25  French  scale),  is  wound 

around  the  root  of  the  scrotum  over  a  layer  of  cotton 

batting.  (Fig.  10.)   The  ends  are  secured  by  means  of  a  small 

clamp,  for  instance,  such  as  are  used  in  hare-lip  operations 


42 


BIER  S    HYPEREMIC    TREATMENT. 


Fig.  10. — Obstructive  hyperemia  for  the  testicles.  The  ends  of 
the  elastic  tube  are  held  by  the  patient,  crossed.  A  piece  of  tape  is 
placed  beneath  to  be  tied  by  an  attendant. 


Fig.  11. — Rubber  tube  for  the  hyperemic  treatment  of  the  testicles; 
ends  crossed  and  clamped  to  the  side  of  the  penis. 


OBSTRUCTIVE    HYPERE.MIA    BY    ELASTIC   TUBE. 


43 


to  make  the  lip  anemic  (Fig.  11);  or  they  are  crossed  and 
then  held  in  place  by  a  piece  of  tape  or  silk  thread,  in  the 
same  way  as  we  tie  a  tube  around  the  inguinal  fold  of  the 
thigh  and  abdomen  in  order  to  produce  Esmarch's  arti- 
ficial anemia  for  the  high  amputation  of  the  thigh.     (Fig. 


Fig.  12. — Rubber  tube  for  the  hyperemic  treatment  of  the  testicles; 
ends  crossed  and  tied.  This,  of  course,  can  be  done  only  by  an  attend- 
ant, except  the  tubes  are  clamped  at  the  crossing  and  the  clamp  is  re- 
moved the  moment  the  knot  is  tied,  being  pushed  off  with  the  finger. 


12.)  The  proper  degree  of  hyperemia  can  thus  be  regu- 
lated in  a  very  simple  manner.  Of  course,  the  effect  of 
the  obstruction,  the  venous  hyperemia  of  the  testicles, 
cannot  be  seen;  the  skin  of  the  scrotum  with  its  engorged 


44  bier's  hyperemic  treatment. 

veins  represents  the  indicator  for  the  proper  degree  of  the 
hyperemia. 

Patients  learn  quickly  to  apply  the  band  themselves. 
However,  they  must  always  remain  under  strict  medical 
supervision. 

If  help  is  at  hand,  it  is  advisable  for  the  patient  to  lie 
down  and  pull  the  diseased  testicle  or  better  both  testicles 
strongly  upward,  so  as  to  form  a  kind  of  a  scrotal  pedicle 
near  the  base  of  the  pars  pendula  penis.  This  pedicle  is 
then  surrounded  two  or  three  times  with  the  tube,  the  ends 
being  knotted,  tied  or  clamped.     (Fig.  10.) 

"2.  OBSTRUCTIVE  HYPEREMIA  BY  MEANS  OF  SUCTION 
APPARATUS. 

Suction  Appa-  For  some  years  Bier  has  been  employing  suction  appar- 
atus (also  called  vacuum  apparatus,  suction  cups,  cupping 
glasses)  for  the  induction  of  artificial  hyperemia.  The 
method  has  been  more  carefully  developed,  however,  by 
R.  Klapp,  who  has  been  connected  with  Bier's  clinic  as 
assistant  for  many  years.  And  now  this  kind  of  technique 
has  been  adopted  in  clinics  and  hospitals  the  world  over. 
Suction  cups  properly  constructed  and  applied  have 
proved  to  be  a  most  efficient  means  of  producing  obstruc- 
tive hyperemia. 

Effect.  By  applying  suction  hyperemia  it  will  be  seen  that  the 

skin  plus  underlying  tissues  are  sucked  into  the  hollow 
of  the  glass.  This  causes  a  rush  of  blood  into  the  respective 
area,  but  the  hyperemia  does  not  involve  the  surface  only ; 
it  also  reaches  into  the  deeper  layers. 

Hyperemia  produced  in  this  way  is  similar  to  that  result- 
ing from  the  application  of  the  elastic  bandage. 


OBSTRL'CTIVE    HYPEREMIA    BY    SUCTION    APPARATUS.     45 

Here,  again,  the  first  rule  is  not  to  overdo.  The  skin 
should  turn  red  or  hluish-red,  but  never  white.  Any  interrup- 
tion of  the  circulation  as  demonstrated  by  anemia  must 
be  strictly  avoided. 

To  be  able  to  employ  the  method  more  generalh^  it  Technique. 
was  necessary  to  have  cupping  glasses,  the  shapes  of  which 
were  adapted  to  the  varying  contours  of  the  body  surface. 
To  meet  this  requirement  glasses  are  now  to  be  had  in 
manifold  sizes  and  shapes,  with  smooth  and  U-shaped 
brims,  the  latter  for  application  to  round  surfaces,  with- 
out exerting  undue  pressure.  To  reduce  the  pressure 
to  a  minimum,  the  brim  is  thickened  and  in  some  cases 
turned  outward. 

In  the  small-sized  glasses  suction  is  obtained  by  a  small 
rubber  bulb  which  is  either  directly  attached  to  the  glass 
(Figs.  13-16)  or  communicates  with  it  by  means  of  a  nib- 
ber  tube.     (Figs.  17-20.)* 

With  gentle  pressure  on  the  rubber  bulb  the  cup  is 
put  in  place  and  the  hand  is  removed  The  cup  will  be 
found  to  adhere  to  the  skin  with  just  sufficient  firmness 
not  to  drop  off.  To  facilitate  air-tight  closure  of  the  cup 
upon  the  skin,  it  is  well  to  spread  a  thick  layer  of  vaselin 
over  the  border.  Here  also,  a  "  too-much  "  must  be  strictly 
guarded  against.  Suction  rnust  never  be  too  strong  and 
never  create  pain. 

The  vacuum  apparatus  of  larger  size  are  applied  with 
a  suction  pump  (Figs.  21  and  22),  which  is  inserted  into 
the  end  of  the  rubber  tube  in  place  of  the  bulb  and  reg- 
ulates the  degree  of  hyperemia. 

*  The  New  York  depot  of  all  suction  glasses  and  apparatus,  pertain- 
ing to  Bier's  hyperemic  treatment,  is  The  Kny-Scheerer  Co.,  289  Ninth 
Avenue. 


46 


BIER  S    HYPEREMIC   TREATMENT. 


In  all  of  the  large-sized  suction  glasses  and  some  of  the 
smaller  ones  a  three-way  stop-cock  is  placed  in  the  tub- 
ing for  the  purpose  of  obtaining  air-tight  closure  of  the 
cup  after  the   desired   degree   of  obstructive  hyperemia 


Fig.  13. 


Fig.  15. 


Fig.  14. 


Fig.  16. 

Figs.  13  to  16. — These  cups  represent  the  simplest  form  of  suction 
glasses.  One  recognizes  the  various  shapes  and  sizes,  the  thickened, 
turned-up  border;  in  some  the  latter  is  curved  U-shaped.  The  rubber 
bulb  is  attached  directly  to  the  glasses.  These  glasses  are  used  in  the 
treatment  of  furuncles  of  smaller  size  and  sinuses. 


has  been  attained,  as  also  to  facilitate  their  removal, 
which  is  of  value  especially  in  connection  with  the  very 
large  cups,  that  cover  the  entire  female  breast.  (Figs. 
23  and  24.) 


OBSTRUCTIVE    HYPEREMIA    BY    SUCTIOX    APPARATUS.     47 

In  making  use  of  these  vacuum  apparatus  we  not  only  Mechanical 
rely  on  the  artificial  hyperemia  they  produce,  but  also, 
and  by  no  means  least,  on  their  mechanical  effect. 

If  we  place  such  a  glass  over  a  diseased  area  which 


Fig.  17. 


Fig.  18. 


Fig.  19. 


Fig.  20. 


Figs.  17  to  20. — Show  glasses  of  simpler  configuration;  a  rubber 
tube  connects  glass  with  bulb;  the  same  can  be  readily  detached,  thus 
rendering  easy  the  sterilization  of  the  glass  by  boiling.  In  the  tube  of 
Fig.  20  a  three-way  stop-cock  is  inserted.  These  cups  are  used  for 
treating  furuncles  of  larger  dimensions,  etc. 


48 


BIER  S    HYPEREMIC    TREATMENT. 


,  ,  Figs.  21  and  22. — These  figures  show  suction  pumps  of  various  cali- 
ber designed  for  the  production  of  the  proper  vacuum  in  apparatus  of 
larger  size;   the  smaller  pump  can  be  worked  with  one  hand. 


Fig.  23. — Suction  glass  for  puerperal  mastitis. 


OBSTRUCTIVE    HYPERE:MIA    BY    SUCTION    APPARATUS.     49 

presents  a  sinus  in  its  middle,  the  pus  and  with  it  bacteria 
are  aspirated  from  the  depth,  slowly  and  painlessly;  often 
necrotic  tissue,  or  even  sequestra  of  small  size,  are  brought 
to  the  surface.  This  suction  effect  is  particularly  valuable, 
for  the  granulations  lining  the  fistulous  tract  or  the  abscess 
cavity  are  in  this  manner  also  brought  under  hyperemia, 


Fig.  2-1. — Suction  glass  for  puerperal  mastitis;  the  projecting  part 
to  the  right  will  collect  the  wound  secretions,  and,  naturally,  is  made 
the  lowermost  part  of  the  glass,  when  in  place. 

and   the   current   of   secretion,  thus   directed   outwardly, 
bathes  and  cleanses  them  gently  but  thoroughly. 

In  thus  using  the  suction  glasses  in  the  treatment  of  Disinfection, 
suppurating  wounds  and  fistulous   tracts,   strict  asepsis 
is,  of  course,  a  sine  qua  non.    After  using,  the  glasses 
must  be  detached  and  boiled.     If  kept  in  a  sterilized 
4 


50 


BIER  S   HYPEREMIC   TREATMENT. 


towel  or  gauze,  or,  if  preferred,  in  a  solution  of  bichlorid 
after  boiling,  the  glasses  will  be  alwaj's  ready  for  use.  If 
proper  care  is  taken  to  prevent  soiling  the  rubber  parts, 


Fig.;  25. 


Rg.  27. 


Fig.  26. 


Fig.  28 


Fig.  29. 

Figs.  25  to  29. — These  figures  represent  vacuum  glasses  shaped 
especially  for  the  collection  of  wound  secretions,  rendering  it  impossible 
for  the  latter  to  enter  or  come  in  contact  with  the  rubber  parts. 


these  need  be  boiled  only  now  and  then  and,  consequently, 
will  last  longer. 

In  order  to  better  avoid  such  contamination  by  pus  and 


OBSTRUCTIVE    HYPEREMIA    BY    SUCTION   APPARATUS.     51 

wound  secretion  special  glasses  are  made  with  a  receptacle 
at  their  lower  end.     (Figs.  25  to  32.) 

Infection  from  the  aspirated  pus  may  further  be  avoided 
by  anointing  with  vaselin  the  border  of  the  glass  as  also 
the  immediate  neighborhood  of  the  wound.  This  precau- 
tion is  especially  indicated  when  treating  furuncles. 


Figs.  30  to  32  show  other  shapes  with  a  special  receptacle  for  the  pus. 
Here,  too,  the  pus  cannot  be  aspirated  into  the  rubber  tube. 


Fig.  30. 


Fig.  32. 


Fig.  31. 


After  the  cupping,  the  skin  is  cleansed  with  a  piece 
of  gauze  or  cotton  soaked  in  ether,  and  a  dry  or  moist 
gauze-  or  an  ointment  dressing  is  applied. 

In  one  of  the  previous  chapters  dealing  with  the  treat-  Abscesses. 


52  bier's  hyperemic  treatment. 

ment  of  infective  processes  by  means  of  the  elastic  bandage, 
it  has  been  stated  that  pus  must  be  evacuated  as  soon 
as  found.  The  same  rule  holds  good  in  the  treatment 
with  suction  cups.  It  would  be  senseless  to  apply  suction 
hyperemia  over  an  abscess  without  first  opening  the 
same.  What  should  be  done,  after  careful  preparation 
and  anesthetization  of  the  skin,  is  to  puncture  the  abscess 
and  then  apply  a  cup  of  proper  size. 

At  the  first  application  a  good  deal  of  blood  will  be  found 
mixed  with  the  aspirated  pus,  but  this  is  of  no  consequence, 
and  will  not  continue. 
Duration  of  The  suction  glasses  are  applied  six  times  five  minutes 

Application.  . 

per  day  with  intervals  of  three  minutes  between  the  appli- 
cations in  order  to  give  the  edema  and  hyperemic  swelling 
an  opportunity  to  disappear.  Thus  the  entire  time  of 
treatment  is  three-quarters  of  an  hour  each  day. 

Of  course,  it  is  not  necessary  to  religiously  adhere  to 
this  proportion  of  time.  Slight  deviations  will  not  matter. 
The  five  to  three  minutes  rule,  which  experience  has  shown 
to  be  followed  by  good  results,  has  been  given  merely  as  a 
guide. 

This  manner  of  treatment  has  yielded  most  gratifying 
results.  A  very  pronounced  degree  of  hyperemia  can 
thereby  be  obtained  in  almost  any  portion  of  the  body 
surface,  and,  as  shown  in  Part  II  of  the  book,  serious  and 
painful  operations  may  thus  often  become  unnecessary. 

The  use  of  the  suction  cups,  too,  can  be  learned  by  the 
patients  and,  after  some  practice,  may  be  entrusted  to 
them,  should  this  become  necessary.  However,  as  a 
rule,  the  attending  physician  should  be  in  permanent  con- 
trol of  the  treatment.    (Fig.  33.) 


OBSTRUCTIVE    HYPEREMIA    BY    SUCTION    APPARATUS.     53 

The  surgeon,  specialist  and  general  practitioner  who 
may  find  a  wide  range  of  application  for  these  suction 
cups  would  best  set  aside  a  room,  next  or  near  to  the 
office,  in  which  patients  requiring  the  suction  treatment 
may  be  attended  to. 

The  same  holds  good  of  hospitals  and  particularly  dis- 
pensaries in  the  large  cities.  They  should  not  only  have 
a  separate  room, — or  at  least   part   of  a  room, — but   a 


Fig.  33. — This  illustration  shows  a  group  of  patients  of  the  Surgical 
Poliklinik  of  the  University  of  Berlin  treated  with  various  suction  cups 
for  suppuration  and  fistulous  tuberculosis. 


specially  trained  assistant  and  nurses,  to  take  charge  of 
such  department. 
As  has  been  stated  before,  pus  and  other  wound  secre-  Dressings  when 

.      ,     1    »  .  ,  p    ,,  Suction       Cups 

tions  are  aspirated  from  smuses  by  means  ot  the  cups,  are  Used. 
This  is  not  only  of  great  practical  value,  but  also  of  benefit 
to  our  patients,  in  that  the  painful  tamponades  of  wounds 
with  gauze  as  well  as  their  drainage  by  means  of  rubber 
tubing  can  usually  be  dispensed  with. 


54  bier's  hyperemic  treatment. 

Thus  the  painful  tamponade  of  felons,  furuncles  and  the 

wounds  resulting  from  multiple  incision  of  the  inflamed 

breast  in  puerperal  mastitis,   etc.,  has  become  obsolete 

and  superfluous. 

Suction  Appara-      After  the  suction  glasses  of  small  size  had  been  practi- 

tus    of    Large 

Size.  cally  tested  as  to  their  value,  the  manufacture  of  stronger. 


Fig.  34. — Illustrating  an  ordinary  suction  apparatus  for  the 
finger  (felon,  etc.)  with  a  convexity  at  the  lower  surface,  designed  to 
receive  the  pus. 

bottle-shaped  vessels  suitable  for  the  reception  of  the 
entire  extremities  was  taken  up.  The  limb  is  pushed  into 
these  vessels  through  an  aperture  at  one  end.  A  rubber 
cuff  is  fitted  snugly  around  the  rim.  It  may  be  necessary 
sometimes  to  apply  a  rubl^er  bandage  in  order  to  secure 
air-tight  closure.    Then  the  air  is  aspirated  and  the  stop- 


OBSTRUCTIVE    HYPEREMIA    BY    SUCTION   APPARATUS.      55 

cock  fastened.  A  very  pronounced  red  hyperemia  will 
soon  ensue.  A  little  later  small  drops  of  water  due  to  the 
evaporation  of  the  perspiration  collect  on  the  inside  of  the 
apparatus. 

This  form  of  hyperemia  can  be  employed  for  various 
therapeutic  purposes.  The  degree  of  suction  required  in 
the  given  case  can  be  readily  regulated. 

Again  it  should  be  stated  that  here,  too,  great  care  must 
be  exercised  not  to  overdo.  The  application  should  he 
absolutely  painless.  It  should  never  interrupt  circulation, 
but  merely  produce  a  moderate  degree  of  congestion. 


Fig.  35. — Constructed  for  the  treatment  of  the  hand.     A  soft  rubber 
band  wound  around  the  cuff  makes  it  fit  air-tight  around  the  arm. 


A  few  simple  specimens  of  these  larger  cups  are  shown  in 
Figs.  34  and  35.  The  smaller  one,  designed  for  the  fingers, 
is  connected  with  a  rubber  bulb;  the  larger  one,  intended 
to  receive  the  whole  hand,  is  worked  by  a  suction  pump. 
For  the  rarefaction  of  the  air  in  the  very  large  apparatus, 
a  correspondingly  large  suction  pump  is  used,  not  unlike 
the  kind  used  by  bicyclists.  By  placing  the  valve  differ- 
ently, a  pressure  pump  is  converted  into  a  suction  pump. 

The  hand  or  foot  or  extremity  placed  within  one  of  these  The   Utility   of 

these  Ai)D&.rfl.~ 
apparatus  is  forcibly  drawn  forward  until  it  meets  an  tus  for  Mobiliz- 

obstacle  in  the  lower  end-wall  of  the  glass,  after  which  it  j^fnts.  *°^ 

turns  in  the  direction  of  least  resistance. 


56  bier's  hyperemic  treatment. 

This  mechanical  effect  can  be  utiHzed  to  advantage  for 


Fig.  36. — Medium  position  for  moving  the  wrist  in  the  vacuum 
glass.  The  illustration  shows  a  large  suction  glass  for  the  entire  forearm. 
The  cuff  clings  firmly  to  the  arm  so  as  to  shut  off  all  air.  The  fingers  and 
hand  are  flexed  or  stretched  with  the  same  force  as  the  arm  is  pulled  into 
the  apparatus  and  are  pressed  against  its  lower  end.  (Figs.  36  to  45, 
inclusive,  demonstrate  the  uses  of  the  suction  apparatus  for  orthopedic 
purposes.  The  hyperemia  and  edema  produced  incidentally  will 
reduce  the  accompanying  pain  to  a  minimum.) 


Fig.  37. — The  illustration  shows  how  dorsal  flexion  of  the  wrist  is 
produced  by  the  vacuum. 


orthopedic  purposes;   viz.,  for  passive  motions  of  stiffened 


OBSTRUCTIVE    HYPEREMIA    BY    SUCTION    APPARATUS.     57 

joints,  pads  or  a  rubber  pillow  or  handles  being  placed  within 
the  apparatus  to  support  and  guide  the  extremity  in  the 


Fig.  38. — By   pressing   the  knuckles   against   the   upper   part  of   the 
support,  volar  flexion  of  the  hand  is  started. 


Fig.   39. — Strongest  volar  flexion;    the  dorsum  of  the  hand  touches 
the  support. 

desired  direction.    The  accompanying  figures  nicely  illus- 
trate the  idea.     (Figs.  36  to  52.) 


58 


BIER  S   HYPEREMIC   TREAT.MENT. 


The  principal  point  in  favor  of  this  new  method  is  its 
gentleness  of  application.     Stiffened  joints  are  in  this  way 


Fig.  40. — Illustrates  the  passive  stretching  of  the  fingers. 


Fig.  41. — Shows  how  the   fingers  are  gently  but   irresistibly  pressed 
into  flexion  by  the  vacuum. 

mobilized  with  much  less  pain  than  could  be  done  with 
orthopedic  apparatus  for  passive  motions. 


Fig.  42. — The  foot-piece  in  place  without  supports.  (Figs.  43  to 
45  demonstrate  the  various  angles  into  which  the  foot  may  be  forced 
by  means  of  correspondingly  shaped  supports.) 


Fig.  43. — Small  cushion  placed  under  the  heel  for  the  treatment  of 

talipes  calcaneus. 

59 


Fig.  44. — A  movable  and  adaptable  support  under  the  fore  part  of  the 
foot  for  the  treatment  of  pes  equinus. 


Fig.  45. — Large  laterally  slanting  cushion  in  place;    the  higher  edge 

supports  the  inner  side  of  the  foot  to  obtain  supination. 

60 


OBSTRUCTIVE    HYPEREMIA    BY    SL'CTION    APPARATUS.     61 

This  is  due  mainly  to  the  fact  that,  incidentally,  a  marked 
hyperemia  is  produced  in  the  respective  joint,  the  consecu- 


Fig.  46. — Example  of  apparatus  for  finger-stretching  with  rack 
and  pinion;  it  is  introduced  into  a  glass  cup.  Various  other  styles 
are  in  the  market  and  still  others  can  be  easily  designed. 


Fig.  47. — Showing  position  of  the  hand,  strapped,  when  the  auxiliary 
apparatus  as  illustrated  in  Fig.  46,  has  been  introduced  into  the  suction 
glass. 


Fig.  48. — The  fingers  successfully  stretched.  The  hand  with  fore- 
arm aspirated  toward  the  bottom  of  the  glass.  The  incidentally  pro- 
duced hyperemia  of  the  part  of  the  extremity  within  the  glass  reduces 
the  accompanying  pains  very  materially. 

tive  vascularity  and  serous  infiltration  of  the  parts  render- 
ing them  limber. 


62 


BIER  S    HYPEREMIC   TREATMENT. 


i^ 

S^B 

"^    ,"1 

^iv^-  ''"v ,        ^ 

1^1^^'""^^^^^^^^^ 

■p^^^^^^^^^l 

^^2^0 

Fig.  49. — Suction  apparatus  for  the  elbow-joint.  The  illustration 
shows  how  the  elbow,  which  when  introduced  was  entirely  extended, 
has  been  bent  slightly  by  the  suction  process.  In  consequence  of  the 
edema  and  hyperemia  produced,  the  accompanying  pain  is  very  slight, 
same  as  in  all  other  cases  in  which  the  glasses  are  used. 


Fig.  50. — Suction  apparatus  for  the  knee-joint,  to  produce  flexion. 
The  rubber  cuffs  close  air-tight;  the  one  around  the  thigh  making 
obstructive  hyperemia  of  the  parts  below  at  the  same  time.  By 
rarefying  the  air  in  the  apparatus  with  a  large  suction  pump  the  knee- 
joint,  which  is  stiff  in  full  extension,  is  made  hyperemia  with  part  of 
thigh  and  leg  and  gently  forced  into  flexion.  The  procedure  is  not 
accompanied  with  any  appreciable  pain. 


OBSTRUCTIVE    HYPEREMIA    BY    SUCTION   APPARATUS.     63 

These  suction  apparatus,  too,  are  used  intermittently. 
A  strong  hyperemia  is  arranged  for,  but  not  sufficiently 


^^ 


Fig.  51. — Suction  apparatus  for  knee-stretching. 

so  to  cause  pain.    It  is  continued  for  five  minutes.     Then, 
by  turning  the  stop-cock,  air  is  admitted.     After  two  to 


Fig.  52. — Illustrates  in  a  diagrammatic  sketch  how  a  contracted 
knee  can  be  gradually  and  almost  painlessly  stretched  by  means  of  the 
suction  apparatus  shown  in  Fig.  51.  The  elastic  air-pressure  bag 
which  fills  the  cut-out  of  the  apparatus  forces  the  knee  downward 
with  atmospheric  pressure,  whilst  the  foot  rests  and  slides  forward  on 
the  little  wheel-cart. 

three  minutes  the  procedure  is  repeated,  until  one-half  to 
three-fourths  of  an  hour  has  passed. 


64  bier's    HYPEREMIC    TREATMENT. 

Of  course,  all  these  appliances  in  order  to  give  full  satis- 
faction, should  be  handled  by  thoroughly  trained  persons 
only,  and  then  under  strict  medical  supervision. 

The  suction  apparatus  just  described,  in  which  the 
mechanical  forces  are  utilized  for  orthopedic  purposes, 
are  but  types  of  a  group  of  similar  ones  designed  by  Klapp. 

With  the  help  of  special  apparatus  most  of  the  large 
joints  of  our  body  can  be  made  to  profit  by  this  treatment. 

It  is  not  our  desire  to  go  into  further  details  here.  Those 
interested  may  study  the  respective  publications  that 
have  appeared  in  medical  literature. 

3.  THE  INDUCTION  OF  HYPEREMIA  BY  MEANS  OF  HOT 

AIR. 

Hyperemia    by      It  has  been  shown  that  it  is  possible  to  produce  a  pro- 
Means  of  Hot  .  ■      p  1-1 
Air,                   nounced  hyperemia  by  means  of  hot  air  of  any  kind. 

Any  part  of  our  body,  brought  near  a  source  emitting 
strong  heat,  becomes  heated  and  turns  bright  red,  or 
hyperemic.  However,  the  hyperemia  produced  in  this 
way  is  different  from  that  induced  by  obstruction.  The 
latter  causes  a  venous  hyperemia;  the  hot-air  hyperemia 
represents  an  arterial  one. 

Heat  for  the  production  of  hyperemia  has  been  employed 
as  long  as  the  art  of  healing  exists.  The  laity,  likewise, 
has  used  it  in  the  shape  of  hot  baths,  hot  fomentations, 
hot  poultices,  sun-baths,  hot-sand  baths,  etc.,  which  find 
their  sequelse  at  the  present  time,  in  electric-light-baths, 
steam-baths,  etc. 

The  effect,  too,  of  hot-air  hyperemia  is  different  from 
that  of  obstructive  hyperemia,  not  only  as  regards  the 
body  but  also  as  to  pathologic  processes. 


IXDUCTIOX    OF    HYPEREMIA    BY    HOT    AIR. 


65 


For  this  reason,  hyperemia  ])roiight  on  by  hot  air  has 
its  own  special  incUcations. 

The  increased  supply  of  arterial  blood  to  any  part  of  the 
body  favors  absorption  of  chronic  exudates,  infiltrations, 
adhesions,  etc.  Therefore,  these  chronic  conditions,  being 
the  result  of  a  previous  acute  inflammation,  are  partic- 
ularly favorably  influenced  by  hot-air  hyperemia. 


"tlat^ 


Fig.  53. — Hot-air  box,  open.  Note  the  board  on  either  side  not  far 
from  tlie  internal  aspect  of  the  opening.  It  takes  care  of  a  more  even 
distribution  of  the  hot-air  current  within  the  box. 


The  second  class  of  cases  that  can  be  advantageously 
treated  by  means  of  hot-air  hyperemia  are  neuralgias  of 
all  varieties. 

With  reference  to  indications  for  this  treatment  details 
will  be  found  in  the  second  part  of  the  book. 

Bier,  who  was  the  first  also  to  make  use  of  hot-air  for 
5 


66  bier's  hyperemic  treatment. 

the  induction  of  hyperemia,  has  made  a  very  careful 
study  of  it  for  many  years,  and  has  been  impressed  with 
its  manifold  advantages  as  compared  to  other  methods. 


Fig.  54. — Shows  the  wooden  hot-air  box  for  the  hand.  Note  the 
manner  in  which  the  felt  cuff  is  made  to  fit  air-tight  by  straps.  A 
thermometer  is  placed  in  one  of  the  apertures  in  the  top,  although 
this  is  usually  unnecessary,  the  patient's  own  feeUng  being  the  best 
index  to  the  proper  degree  of  heat. 

Dry,  hot  air  permits  of  the  use  of  a  very  high  degree  of 
heat,  without  injury  or  pain  to  the  respective  part. 


INDUCTION    OF    HYPEREMIA    BY    HOT    AIR. 


67 


Dry  hot  air  finds  practical  application    in  surgery  in 
two  ways: 

1.  By  means  of  the  hot-air  boxes  or  chambers. 

2.  By  way  of  the  hot-air  douche. 


Fisr.  55. — Shows  the  hot-air  box  for  the  elbow. 


The  most  useful  hot-air  boxes  are  quadrangular  wooden  Hot-air  Boxes. 
chambers  of  simple  and  inexpensive  construction.    Any 
carpenter  can  make  them.     The  one  thing  to  be  observed 
is  that  the  wood  is  well  seasoned  and   free   from  resin 


68 


BIER  S    HYPEREMIC    TREATMENT. 


(alder,  poplar),  as  the  latter  woultl  become  liquid  from 
the  heat  and  might  drip  down  upon  the  exposed  parts. 
The  boxes  (Figs.  53  to  61)  are  provided  with  a  lid 
which,  according    to    necessity,  shows  one  or  two   open- 


Fig.  56. — Shows  the  hot-air  box  for  the  shoulder;  apparatus  is  sus- 
pended from  the  ceiling,  an  arrangement  which  enables  the  surgeon  to 
use  the  same  apparatus  for  either  side.  This  is  easily  done  by  revers- 
ing the  chair.  This  arrangement  will  be  found  especially  useful  in 
dispensaries,  or  in  the  offices  of  physicians  who  practise  in  places  where 
institutes  for  hot-air  treatment  are  not  at  their  disposal. 


ings  for  the  reception  of  the  limb  (arm  or  leg).  These 
openings  are  lined  with  cuffs  of  some  insulating  material 
(broad  flaps  of  felt),  which  are  fastened  around  the 
limb   by   means  of   straps   and   buckles.     Of  course,  the 


IXDUCTIOX    OF    HYPEREMIA    BY    HOT    AIR, 


69 


cuff  must  never  be  applied  so  tight  as  to  impede  circu- 
lation. On  one  side  of  the  chamber  is  found  an  attach- 
ment for  the  reception  of  the  chimney  of  the  lamp, 
through  which  the  current  of  hot  air  enters.  For  the 
purpose  of  a  more  even  distribution  of  the  hot-air 
current  and  the  better  protection  of  the  limb,  a  board  is 


Fig.  57. — The  same,  with  the  box  placed  on  a  small  table. 


placed  inside  the  box  not  far  from  the  internal  aspect 
of  the  opening.  (See  Fig.  53.)  For  the  same  reason  the 
chamber  must  not  be  of  too  small  size.  The  larger  it  is  in 
proper  proportion  to  the  circumference  of  the  limb  the 
more  evenly  distributed  will  be  the  hot-air  current.  The 
lid  contains  one  or  two  additional  openings  for  the  escape 


70 


BIER  S   HYPEREMIC   TREATMENT. 


of  air,  which  should  be  in  constant  motion.  This  ventilation 
makes  the  air  dry  and  allows  the  perspiration  to  evaporate. 
It  is  a  well-known  fact  that  high  degrees  of  hot  air  are 
much  better  borne  in  a  dry  than  in  a  moist  atmosphere. 

The  beginner  may  introduce  a  thermometer  through  one 
of  the  holes  in  the  lid,  which  will  show  him  the  degree  of 


Fig.  58. — Shows  the  hot-air  chamber  for  the  foot;  an  electric  stove 
suppHes  the  heat.*  Of  course,  the  patient  who  can  leave  his  bed  could 
as  well  sit  on  a  chair  with  the  box  placed  on  another  chair.  If  the 
patient  is  confined  to  bed,  the  box  may  be  placed  in  the  latter. 


heat  within  the  chamber.  But  the  patient's  own  feeling 
ought  to  be  the  best  guide  for  the  proper  temperature. 
There  must  he  no  pain  nor  even  annoyance  from  the  heat. 

*  A  spscial  electric  apparatus  is  required  to  generate  the  degrees 
of  heat  needed.  The  ordinary  small  electric  stove  is  not  capable  of 
furnishing  it. 


INDUCTION    OF   HYPEREMIA    BY    HOT    AIR. 


71 


If  the  temperature  is  gradually  increased,  a  surprisingly 
high  degree  of  heat  can  be  borne  by  the  patient.  Often 
the  thermometer  registers  as  high  as  250°  to  260°  F.  (120° 
to  125°  C.)  and  more,  at  least  in  the  upper  part  of  the 
chamber. 

In  this  connection  it  must  be  borne  in  mind  that  great  Burns. 


Fig.  59. — Shows  the  hot-air  chamber  for  the  knee;    a  gas  lamp  is  the 
source  of  heat. 


heat  makes  the  parts  less  sensitive.  //  due  care  is  not 
taken  a  hum  of  the  second  degree  may  occur,  without  the 
patient's  being  aware  of  it,  until  after  the  sitting,  when 
he  will  find  a  blister. 

To  make  the  chambers  more  durable,  they  are  covered 


72 


BIER  S    HYPEREMIC   TREATMENT. 


with  cloth.     The  inner  surface  is  soaked  in  sihcate,  thus 
reducing  the  danger  of  fire. 

As  already  stated,  the  hot  air  is  carried  into  the  box 
through  a  small  funnel-shaped  sheet-iron  chimney  which 
is  curved  at  its  upper  end  to  meet  the  hole  in  the  side  of 


Fig.  GU. — Shows  the  hot-air  chamber  for  the  whole  leg.  Here  again 
the  source  of  heat  is  an  electric  stove,  an  arrangement  which  simplifies 
matters  considerably. 

the  chamber.     An  alcohol  or  gas  lamp  placed  on  a  stand 
underneath  the  funnel  supplies  the  heat. 

The  regulation  of  the  heat  is  effected  by  the  size  of  the 
flame,  as  also  by  raising  or  lowering  the  lamp  on  its  stand. 
The  lower  the  lamp  the  less  heat  it  furnishes. 


INDUCTION    OF    HYPEREMIA    BY    HOT    AIR.  73 

When  heating  with  gas,  care  must  be  taken  never  to 
have  any  gas  enter  the  box  which  might  become  the  cause 
of  an  explosion.  The  larnp  should  be  lighted  before  it  is 
placed  under  the  funnel. 

A  glance  at  the  cuts  will  demonstrate  how  the  patient 
should  be  placed.  He  should  be  in  as  comfortable  a 
position  as  possible  during  the  treatment. 

It  has  to  be  mentioned  that  tips  of  toes  and  fingers 


Fig.  61. — Shows  the  hot-air  chamber  for  both  hips. 

do  not  stand  very  great  heat.  This  is  due  partly  to  the 
presence  here  of  the  large  number  of  nerves,  partly — in 
the  case  of  the  toes  at  least — to  the  fact  that  they  reach 
into  the  upper  portion  of  the  chamber  in  which  the  ther- 
mometer always  shows  a  higher  temperature.  To  pre- 
vent injury,  these  parts  are  either  wrapped  in  asbestos, 


74 


BIER  S   HYPEREMIC   TREATMENT. 


or  the  chamber  for  the  foot  is  fitted  with   a  toe-pro- 
tector. 


Fig.  62. — Shows  the  hot-air  douche  applied  for  trigeminal  neuralgia. 
The  patient  himself  directs  the  nozzle,  bringing  it  as  close  to  the  affected 
area  as  he  can  stand  it.  He  should  keep  his  eyes  shut.  Application, 
about  one-half  hour  daily.  If  possible,  massage  should  immediately 
follow  the  procedure. 

The  illustrations  show  nicely  how  the  various  joints  are 
treated. 


INDUCTION    OF   HYPEREMIA   BY   HOT   AIR. 


75 


First  the  extremity  is  comfortably  placed  in  the  box 
and  the  hd  closed.  Then  the  lamp  is  lighted  and  placed 
underneath  the  funnel,     WTien  a  comfortable  degree  of 


"5??5ta*i>~-.*?r 


Fig.  63. — Shows  the  hot-air  douche  apphed  for  sciatica.  Here  the 
heat  is  suppUed  by  an  electric  stove.  The  patient  again  himself 
directs  the  tube  toward  the  sensitive  area,  spraying,  as  it  were,  the  sur- 
face of  the  body  with  hot  air.  The  distance  of  the  tube  from  the  skin 
regulates  the  temperature.  The  douche  should  be  taken  as  hot  as  the 
patient  will  tolerate. 

heat  has  been  obtained,  it  must  be  the  operator's  aim  to 
continue  the  same  temperature.    After  one-half  to  one  hour 


76  bier's  hyperemic  treatment. 

the  light  is  extinguished,  and  a  few  minutes  later  the  lid  of 
the  box  opened.  It  is  detrimental  to  have  the  temperature 
change  abruptly.  A  pronounced  hyperemia  of  the  part 
will  be  noticed.  Usually  profuse  perspiration  has  set  in, 
which  should  be  carefully  wiped  off. 

If  the  patient's  condition  makes  it  seem  wise,  the  treat- 
ment may  be  given  every  other  day  instead  of  daily,  and 
for  a  shorter  period,  at  least  in  the  beginning. 

The  chamber  for  the  shoulder  needs  a  few  special  words 
of  explanation.  As  will  be  seen  from  the  illustration, 
the  arm  is  introduced  into  the  box  through  a  sleeve-like 
attachment;  the  hand  is  pushed  out  again  through  an 
aperture  in  the  bottom.  The  apparatus  is  hung  up  against 
or  attached  to  the  wall  of  the  room  by  means  of  rings. 
It  can  thus  be  easily  turned  around,  so  that  one  and  the 
same  box  may  be  utilized  for  right  and  left  side. 

There   have   been   placed  upon   the   market   so-called 

"Universal  Boxes, "to  be  used  for  a  number  of  different 

joints.     They  are  not  recommended. 

Hot-air  For  the  hot-air   douches   the   chimney  of  the  hot-air 

Douches. 

box  is  utilized.     It  is  fitted  with  a  pipe  about  30  inches 

(75  cm.)  long,  which  moves  in  a  hollow  ball  joint.     (See 

Figs.  62  and  63.) 

If  the  douche  is  used  in  the  neighborhood  of  the  eyes, 
the  latter  must,  of  course,  be  kept  shut. 

The  sittings  are  for  one-half  hour  daily.  If  possible, 
the  application  should  be  immediately  followed  by  mas- 
sage. The  degree  of  heat  is  lowered  as  the  improvement 
progresses. 

Electricity  also  may  be  employed  for  heating  the  air 
in  these  apparatus,  thus  doing  away  with  the  products  of 


INDUCTION    OF    HYPEREMIA    BY    HOT    AIR.  /  i 

combustion  of  alcohol  and  gas.  ^^^lile  the  appliances 
arranged  for  the  use  of  electricity  are  simpler  to  handle, 
they  are  more  costly.  It  certainly  would  seem  advisable 
to  buy  one  of  the  less  expensive  apparatus  first. 

Patients  with  often  recurring  attacks  of  rheumatism 
or  neuralgia  can  use  the  hot-air  boxes  or  douche  at  their 
homes  under  the  direction  of  a  physician. 


Special  Part. 


THE  TREATMENT  OF  SPECIAL  DISEASES  BY  MEANS 
OF  ARTIFICIAL  HYPEREML^» 

In  now  turning  to  the  discussion  of  the  treatment  of 
various  diseases  with  the  help  of  Bier's  method,  only  such 
will  be  considered  at  length,  regarding  which  sufficient 
experience  has  been  collected  to  warrant  us  in  recommend- 
ing the  use  of  the  method. 

There  is  no  doubt  that  this  range  of  application  will 
widen  as  time  goes  on. 

To  enable  the  reader  to  readily  distinguish  between  the 
diseases  in  which  the  method  has  already  been  thoroughly 
and  successfully  tried,  clinically,  and  those  in  which  it  is 
still  in  an  experimental  stage,  large  type  will  be  used  for 
the  former  class  of  diseases,  smaller  for  the  latter. 

Only  facts  are  stated  and  suggestions  added  without 
mention  of  the  names  of  the  authors. 

A  bibliography  on  hyperemic  treatment  will  be  published 
by  us  in  the  near  future. 


78 


CHAPTER  IV. 
HYPEREMIC  TREATMENT  IN  SURGERY. 

TRAUMATISMS. 

The  powerful  effect  of  the  hot-air  bath  can  be  made  use  Contusions  and 

Distortions, 
of  to  best  advantage  in  bringing  exudates  of  blood  to  more 

rapid  absorption. 

While  the  effusion  of  a  small  amount  of  blood  into  the 
soft  parts,  subcutaneous  connective  tissue,  or  between 
the  muscles,  usually  takes  care  of  itself,  more  profuse 
exudations,  or  cases  in  which  rapid  absorption  is  desirable 
for  special  reasons,  are  greatly  benefited  by  hot-air  appli- 
cations of,  say,  one  hour  per  day.  Such  treatment  is 
superior  to  prolonged  obstructive  hyperemia  plus  massage 
or  massage  alone.  It  is  easily  applied  and  causes  less 
discomfort  to  the  patient. 

In  the  frequent  contusions  of  the  fingers,  especially  of 
the  third  phalanx  carrying  the  nail,  immediate  short 
gentle  massage — just  to  overcome  the  first  pain — followed 
by  obstructive  hyperemia  with  an  elastic  band  around 
the  base  of  the  first  phalanx,  twice  eleven  hours  per  day, 
will  stop  the  pain  and  facilitate,  in  conjunction  with  hot- 
air  treatment,  absorption  of  the  uncosmetic  subungual 
exudate.     (See  Fig.  64.) 

In  cases  of  severer  injury  to  a  joint,  in  which  the  blood 
quickly  fills  the  synovial  sac,  it  is  of  greatest  importance 
that  this  blood  be  promptly  and  thoroughly  absorbed,  as 

79 


80  bier's  hyperemic  treatment. 

otherwise  fibrous  union  of  the  surfaces  of  the  joint  with 

pronounced  stiffness  may  set  in. 

Traumatic  Hy-      An  example  of  this  class  of  cases  is  the  acute  traumatic 
drops  of  the  .  .       ,    ,       ,  ...         ,,  ,.  .       ,, 

Knee.  synovitis  of  the  knee,  due  to  a     sprain     or     distortion, 

the  so-called  "traumatic  hydrops"  of  the  knee. 

A  correct  diagnosis  is  of  greatest  importance  in  these 


Fig.  64. — The  illustration  shows  a  small  size  elastic  band  (a)  around 
base  of  forefinger,  producing  a  degree  of  hyperemia  which  usually 
suffices  for  prophylactic  work. 

cases,  especially  with  reference  to  a  beginning  joint  tuber- 
culosis {tuberculous  hydrops). 

Bier  advocates  aspiration  of  the  affected  joint  in  severe 
cases  only;  that  is  to  say,  cases  in  which  the  joint  is 
very  much  swollen  from  the  effusion  of  blood  and  synovial 
fluid,  or  in  chronic  cases  when  the  blood  has  been  partly  re- 
placed by  serum,  and  hyperemic  treatment  proves  inefficient 


TRAUMATISMS.  81 

In  ordinary  cases  a  hot-air  bath  is  advised.  The  patient 
is  kept  in  bed  during  the  first  few  days  after  the  injury; 
then  he  may  get  up  and  gently  exercise  the  joint,  although 
it  is  well,  in  the  beginning,  to  apply  a  slightly  compressing 
flannel  bandage. 

If  no  improvement  be  noticeable  within  a  reasonable 
time,  aspiration  will  have  to  be  resorted  to. 

It  is  not  claimed  that  hyperemia  will  here  crowd  out  of 
existence  all  other  well-known,  time-honored  methods, 
such  as  elastic  compression  with  or  without  previous 
aspiration,  splints,  Priessnitz  dressings,  etc.  The  hyperemic 
treatment  is  but  another,  though  most  valuable  and  power- 
ful as  well  as  gentle  method  in  the  treatment  of  this  trouble, 
which  will  render  superfluous  in  a  certain  proportion  of 
cases  aspiration  and  prolonged  rest  in  bed. 

The  painful  swelling  of  a  recent  fracture  involving  the  Joint  Frac- 

turcs 
neighboring    joint,   with    its    inflammatory   irritation,    is 

readily  controlled  by  this  treatment.     A  typical  Colles's 

fracture    may    serve    as    an    example:    After    thorough 

reduction,  the  hand  is  fixed  on  a  splint  for  eight  to  ten 

days.    Then  the  latter  is  definitely  removed  and  a  hot-air 

bath  lasting  from  one-half  to  three-fourths  of  an  hour 

daily  administered.     Only  in  the  event  of  very  pronounced 

original  deviation  of  the  fragments  is  the  splint  applied 

during  the  interval.     In  the  ordinary  case  there  is  no  longer 

any  tendency  to  a  recurrence  of  the  misplacement  about 

one  week  after  the  injury.     Soon  after  the  removal  of  the 

splint  active  and  passive  exercises  plus  massage  are  added. 

This  procedure  shortens  the  time  of  healing  and  insures  a 

useful  limb. 

Bier  approves  of  immobilization  of  the  joints  only  on 

6 


82  bier's    hyperemic  treatment. 

strict  indication.  He  is  of  the  opinion  that  fixation  spHnts 
favor  the  troublesome  stiffening  of  the  joints,  which  so 
often  resists  all  and  every  mode  of  treatment. 
Delayed  Union  Before  resorting  to  operation  in  cases  of  delayed  union 
following  fracture,  or  of  a  false  joint  (pseudarthrosis), 
hyperemic  treatment  deserves  a  thorough  trial,  provided 
the  :c-ray  picture  permits  of  excluding  interposition  of 
muscle  substance.* 

In  specific  cases  the  further  addition  of  antispecific 
treatment  will,  of  course,  be  an  advantage. 

Case. — Man,  twenty-four  years;  direct  fracture  (auto- 
•  mobile  crank)  within  lower  third  of  radius;  frequent 
attempts  at  reduction  and  consequent  changes  of  splints 
at  dispensary  clinic,  on  account  of  radiographs  showing 
unsatisfactory  apposition;  oblique  fracture;  no  union; 
absolutely  no  callus  at  end  of  third  week.  Before  following 
surgeon's  advice  to  operate,  it  is  decided  to  try  hyperemic 
treatment.  Plaster-of-Paris  splint  by  means  of  plaster 
bandage  molded  directly  on  vaselined  dorsum  of  meta- 
carpus, carpus,  forearm,  and  lower  third  of  arm,  putting 
wrist  and  elbow-joint  at  rest;  short  volar  plaster  splint 
(molded  in  the  same  manner);  bone  thus  absolutely 
immobilized.  Application  of  elastic  bandage  around  arm 
eleven  out  of  every  twelve  hours;  perfect  comfort.  Ob- 
structive hyperemia  continued  without  interruption,  ex- 
cept the  two  hours'  intermission  daily,  and  massage  of 
arm  muscles,  for  six  weeks.     Perfect  union;   useful  hand. 

*  A  new,  most  interesting,  and  important  use  of  the  patient's  own 
blood  for  the  treatment  of  a  false  joint  after  fracture  has  been  made  by 
Bier.  He  injects  from  20  to  40  c.c.  of  the  patient's  own  blood,  with- 
drawn from  the  arm  vein  by  means  of  a  strong  glass  syringe,  directly 
into  the  region  of  the  pseudarthrosis.  This  produces  an  acute  inflam- 
matory reaction  with  following  pronounced  callus  formation.  Excel- 
lent results  have  been  obtained.  (See  V.  Schmieden,  The  Treatment  of 
pseudarthrosis  and  retarded  callus  formation  by  injection  of  blood, 
Journal  of  the  American  Medical  Association,  1907,  vol.  49,  page  395.) 


TRAUMATISMS.  SS 

It  may  here  be  mentioned  that  hyperemic  treatment 
was  first  tried  in  surgery  for  delayed  union  of  fractures. 
The  names  of  Ambroise  Pare,  von  Dumreicher,  and  Nicola- 
doni  of  Vienna  (1875),  Thomas  of  London  (1886),  Hel- 
ferich  of  Greifswald  (1887),  are  connected  with  this  kind 
of  work.     (See  Literature  at  end  of  this  volume.) 

It  is  not  a  rare  occurrence  that  convalescents  from  frac-  Refracture. 
ture — especially  if  using  crutches — fall  and  refracture  the 
bone  at  the  original  site  of  injury.  In  these  cases  the 
time  for  definite  union  can  be  materially  shortened  if 
obstructive  hyperemia  be  made  to  assist  the  effect  of  the 
required  splint. 

This  treatment  refers  principally  to  fracture  of  such 
bones  as  cannot  be  treated  with  a  walking  splint  (middle 
or  upper  third  of  femur) ;  now  and  then,  also  to  refractures 
of  the  upper  extremity. 

In  cases  of  the  crepitant  form  of  tenosynovitis  which  Tenosynovitis, 
not  infrequently  develops  within  the  extensor  sheaths  or 
between  these  and  the  muscles  of  the  forearm  after  over- 
exertion, a  longer  immobilization  is  discarded,  same  as  in 
joint  fractures.  Here  the  hand  is  not  placed  on  a  splint, 
not  even  in  the  beginning,  the  only  treatment  employed 
being  a  hot-air  bath  once  a  day. 

Still  better  results  are  often  obtained  in  the  latter  class 
of  cases  by  obstructive  hyperemia.  The  elastic  bandage 
is  applied  for  twenty  to  twenty-two  hours  per  day  with  two 
intermissions  of  one  to  two  hours  each.  So  long  as  crepi- 
tation and  pain  persist  no  hard  work  should  be  undertaken. 

While  the  symptoms  would  probably  subside  in  simpler 
way  and  more  speedily  if  a  splint  were  applied  in  these 
cases,  it  has  been  observed  that  in  that  event  the  trouble 


84  bier's  hyperemic  treatment. 

is  very  apt  to  recur  as  soon  as  the  patient  resumes  his 
former  occupation.  Without  the  use  of  a  sphnt,  the 
result  is  more  permanent. 

INFLAMMATIONS. 
ACUTE  INFECTIONS.* 

Furuncles  and  Carbuncles. 

These  represent  a  type  of  acute  local  infection  and 
merit  special  discussion  on  account  of  their  practical 
importance  and  frequency  of  occurrence. 

Bier's  hyperemia  is  easy  of  application  and  offers  special 
•advantages  over  other  methods  of  treatment  in  these  cases. 

Furuncles  as  well  as  carbuncles  are  best  treated  with  suction 
cups,  which  may  be  applied  in  any  stage  of  the  trouble. 
Technique.  If  a  suction  cup  be  placed  over  a  furuncle,  a  red  hyperemia 

will  be  easily  produced.  If  the  cup  be  of  sufficient  size 
to  reach  over  to  parts  not  involved  by  the  inflammation, 
its  application  will  cause  no  pain.  The  suction  must  be 
of  mild  degree.  If  the  borders  of  the  glass  are  well  anointed 
with  vaselin,  they  will  adhere  to  the  skin  without  difficulty, 
even  though  the  air  within  be  but  slightly  rarefied. 

The  treatment  is  given  but  once  a  day,  for  three-fourths 
of  an  hour.  That  is  to  say,  the  suction  cup  is  applied  six 
times  during  this  period,  with  regular  intermissions  of 
two  to  three  minutes. 

If  applied  in  the  early  stage  of  the  trouble,  this  treat- 
ment will  usually  prevent  suppuration.  If,  however,  the 
yellow  blister  has  already  developed,  the  formation  of  a 

*  The  various  acute  surgical  infectious  inflammations  are  arranged 
according  to  the  degree  of  difficulty  in  the  technique  of  hyperemic 
treatment  and  the  amount  of  careful  supervision  required  for  carrying 
it  out  properly. 


FURUNCLES  AND  CARBUNCLES.  85 

slough  (core)  can  rarely  be  avoided.  In  that  event  the 
suction  glass  may  be  employed  to  advantage  in  hastening 
the  process  and  materially  reducing  the  concomitant  pains. 
It  must  be  remembered  in  suppurative  cases  to  always 
thoroughly  anoint  the  surrounding  skin  with  vaselin  in 
order  to  guard  against  further  infection  by  the  staphy- 
lococcus pyogenes  aureus.  If  a  crust  has  formed  over 
the  hole  owing  to  scanty  secretion,  this  should  be  removed 
with  a  forceps  before  the  cup  is  applied. 

The  hyperemic  treatment  of  furuncles  by  means  of  suc- 
tion glasses  prevents  the  infectious  process  from  extending 
into  the  deeper  tissues. 

If  suppuration  has  already  set  in,  the  pus  and  central 
slough  are  gently  aspirated  from  the  depth  of  the  infected 
focus,  after  the  yellow  blister  has  been  clipped  off  with  a 
pair  of  curved  scissors. 

In  exceptional  cases  only  will  it  be  necessary  to  make  incision, 
an  incision;  but  then  only  a  very  small  one,  just  sufficiently 
large  to  establish  an  opening.  The  large  and  painful  deep 
cross-cuts  into  the  surrounding  healthy  tissues,  or  extir- 
pation of  the  entire  infected  area,  with  its  tedious  and 
painful  after-treatment  by  tamponade,  need  no  longer  be 
practised.  Even  furuncles  of  large  size  may  thus  be 
healed  with  a  very  small  scar,  no  larger  than  the  orifice 
through  which  the  pus  found  its  exit. 

If  patients  do  not  care  about  the  size  of  the  scar,  a  some- 
what longer  incision  followed  by  regular  suction  will 
often  hasten  the  process  of  healing. 

A  loose  ointment  or  wet  antiseptic  dressing  is  applied  Dressings, 
after  suction. 

The  treatment  should  be  continued  until  all  infiltration  Duration  of 

has  subsided.  Treatment. 


86  bier's  hyperemic  treatment. 

Size  of  Cups.  It  may  be  difficult  at  times  to  obtain  cups  of  proper 

size  and  shape  to  cover  a  large  infiltrating  carbuncle;  but 
we  should  not  allow  this  to  stand  in  the  way  of  our  employ- 
ing this  efficient  and  gentle  treatment.  With  a  little  extra 
effort  we  shall  usually  succeed  in  getting  what  we  need, 
and  our  patients  will  be  grateful.     (Fig.  65.) 

Although  the  skin  usually  presents  the  picture  of  a  sieve 
owing  to  the  manifold  small  holes  that  give  exit  to  the  pus, 
a  correct  suction  treatment  will  fully  preserve  the  skin, 
just  leaving  a  number  of  disseminated  dot-like  scars. 

Case.  College  boy;  sixteen  years;  in  camp  during 
summer  vacation,  develops  furuncle  of  neck;  poultices; 
careless.  Soon  second  and  third  yellow  blister  appear; 
infiltration  spreads.  Carbuncle;  multiple  perforations. 
Now  calls  for  surgical  aid.  Far-reaching  slough.  Radical 
operation  would  have  spoiled  his  and  surgeon's  vacation. 
Proper  size  of  suction  cup  fortunately  on  hand.  Relatives 
instructed  as  to  application;  wet  ^  per  cent,  carbolic 
acid  dressing  after  suction  treatment.  Patient  takes 
daily  swims  in  lake.  Seen  by  surgeon  now  and  then; 
no  interference  with  vacation.  Wounds  close  on  eleventh 
day;  skin  preserved;  a  few  small  retracted  scars  in  place 
of  former  perforations. 

Naturally  such  a  treatment  will  in  extensive  infiltrations 
often  take  several  weeks,  but  usually  no  longer  than  the 
old  method  of  radical  operative  procedure  requires,  until 
cicatrization  has  set  in. 
Multiple  Multiple  and  generalized  furunculosis  has  been  success- 

fully treated  by  means  of  suction  hyperemia.  Of  course, 
the  treatment  takes  a  great  deal  of  time,  but  the  result 
amply  compensates  both  doctor  and  patient. 

General  medicinal  and  hygienic  regime  should  not  be 
omitted  in  these  cases. 


FURUNCLES    AND    CARBUNCLES.  87 

While  the  busy  practitioner  may  often  find  it  next  to 
impossible  to  give  the  time  required  by  this  method, 
he  would,  nevertheless,  better  bear  it  in  mind  in  the  event 
of  the  question  of  the  cosmetic  effect  coming  up  for  dis- 
cussion. 

Not   infrequently  a  furuncle  of   the  extremity  is   com-  Lymphangitis 

with  Furuncu- 
plicated  with  lymphangitis    and   regional  lymphadenitis,  losis. 


m/KKSmmmmA 


Fig.  65. — Illustrates  the  application  of  Klapp's  suction  cup  in  a  patient 
afflicted  with  a  carbuncle  of  the  neck. 

In  such  cases  it  is  advisable  to  treat  the  furuncle.  Its 
improvement  will  beneficially  influence  the  sequelae, 
except  the  glands  suppurate.     (See  p.  86.) 

Lymphangitis  of  the  lower  extremity  requires  rest  in 
bed. 

Experience  has  shown  that  furuncles  occurring  in  dia-  The  Treatment 

...  ,      .  .       ,  .of  Furuncles  in 

betic  patients  may  w^ell  be  treated  with  suction  hyperemia.  Diabetics. 


88  bier's  hyperemic  treatment. 

In  view  of  the  greater  tendency  in  these  cases  to  pressure 
necrosis,  special  care  is  necessary  to  see  that  undue  pres- 
sure of  the  glass  is  avoided. 
Furuncle  of  Lip.  The  furuncle  occurring  upon  the  lip  deserves  special 
mention.  It  is  known  that  progressive  infection  of  the 
lymphatic  system  and  sepsis  often  follow  in  its  trail. 
This  danger  must  not  be  lost  sight  of  when  hyperemic 
treatment  is  decided  upon,  and  the  surgeon  who  does  not 
thoroughly  master  the  technique  of  the  method  would 
better  at  once  resort  to  the  knife.  On  the  other  hand, 
those  who  have  acquired  the  necessary  experience  with 
the  method  may  well  employ  suction  hyperemia  even  in 
these  dangerous  cases,  and  thereby  save  their  patients 
the  ugly,  disfiguring  scars  resulting  from  radical  treat- 
ment. Only  small  incisions  are  made  in  order  to  give 
exit  to  the  pus  as  soon  as  it  has  formed,  and  the  patient 
must  be  kept  under  closest  observation.  Much  experience 
and  tact  are  needed  to  successfully  work  on  this  border- 
land, to  be  able  to  judge  when  operative  intervention  is 
indicated. 

Of  course,  if  patients  do  not  mind  the  resulting  scars,  an 
early  proper  incision  remains  the  simplest  road  to  recovery. 

Even  if  there  should  be  fatal  results  from  hyperemic 
treatment  of  these  cases,  it  is  but  fair  to  remind  the  pro- 
fession that  not  all  patients,  promptly  operated  upon  with 
the  knife,  recover. 

In  neglected  cases  immediate  operation  alone  should 

come  into  consideration. 

Technique.  As  to  the  technique,  it  should  be  stated  that  upon  face 

and  lip  cups  of  small  size  with  slightly  U-shaped  border 

should  be  used,  and  gentle  hyperemia  only  applied.     A 


FURUNCLES  AND  CARBUNCLES. 


89 


Fig.  66. — Furuncle  of  lip. 


Fig.  67. — Same  patient  as  Fig.  66,  after  one  week's  treatment. 


90 


BIER  S    HYPEREMIC   TREATMENT. 


Obstructive 
Hyperemia  by 
means  of  the 
Neck-band. 


strong  suction  is  a  technical  mistake;  it  is  never  of  benefit, 
and  often  produces  extravasation  of  blood  under  the  cup, 
followed  by  ugly,  pigmented  spots  persisting  for  many  days. 
For  furuncles  of  the  face  and  neck,  obstructive  hyper- 
emia around  the  neck  is  also  beneficial.  Rules  for  its 
use  have  been  laid  down  above.  It  is  applied  for  fifteen 
to  twenty-two  hours  per  day,  with  various  intermissions,  and 
calls  forth  a  pronounced  edematous  swelling  of  the  face, 
particularly  in  the  loose  connective  tissue  of  the  eyelids. 
The  reaction  resulting  from  this  artificial  hyperemia  is 
more  marked  in  acute  cases. 

Case. — Man,  sixty-two  years;  furuncle  of  lip;  trouble 
began  eight  days  previously  with  chills  and  fever,  increasing 
swelling,  great  pain.  Elastic  neck  band  for  twenty-two 
hours  per  day;  two  hours  intermission;  no  incision; 
pronounced  edema  of  face;  pain  materially  lessened. 
(See]Fig.  66.)  Next  day  dried  blister  lifted  off  with 
forceps;  suppuration.  Forty  hours  later  slough  begins  to 
loosen;  general  condition  much  improved;  treatment  con- 
tinued; time  of  application  reduced  after  three  days.  Dis- 
charged one  week  after  admission  to  hospital.  (See  Fig.  67.) 

Best  results  are  obtained  from  the  treatment  if  applied 
early.  Patients  subject  to  frequent  attacks  of  this  trouble 
should,  therefore,  be  instructed  to  consult  their  physician 
just'as  soon  as  the  first  symptoms  become  evident. 


Abscesses,  Acute  Lymphadenitis,  Infected  "Wounds.   Acute 
Infectious  Inflammations  "Within  the  Mouth 

AND  OF  THE  FaCE. 

Abscesses,  The  treatment  of  abscesses,  as  also  of  the  other  affec- 

tions mentioned  under  the  above  heading,  does  not  differ 
much  from  that  of  furuncles  and  carbuncles. 


ACUTE    LYMPHADENITIS.       INFECTED    WOUNDS.  91 

The  physician  who  has  learned  to  handle  the  suction 
glasses  in  the  latter  cases  will,  naturally,  want  to  make 
use  of  the  same  in  other  local  inflammations. 

The  rules  are  the  same:  Every  abscess  should  be 
promptly  incised. 

The  small  but  troublesome  abscesses  found  in  the  axilla, 
as  a  result  of  suppuration  of  the  sudoriferous  glands,  yield 
to  this  treatment  in  a  most  gratifying  manner. 

After  rib-resection,  incision,  and  drainage  of  recent  Empyema, 
empyemas  a  large  suction  cup,  applied  daily,  for  thirty 
to  forty-five  minutes,  may  shorten  considerably  the  time 
of  healing,  which  is  ordinarily  used  in  this  class  of  cases. 
It  will  ably  assist  the  most  modern  treatment  of  this 
trouble,  viz.,  the  immediate  (and  repeated)  distention  of 
the  lung,  after  evacuation  of  the  pus,  with  the  aid 
of  a  differentiated  pressure  apparatus  used  for  intrathor- 
acic operations. 

With   proper   care   and   technique,    suction   hyperemia  Acute  Lymph- 
adenitis, 
will    cure  many    of  these    cases.     It    seems   well   worth 

while  to  give  the  time  and  attention  required  by  the 
hyperemic  treatment  also  in  these  cases.  It  certainly 
is  of  importance  if,  in  case  of  a  localized  infection,  a  group 
of  glands  in  the  axilla  or  groin  can  be  preserved.  Extir- 
pation is  not  always  a  minor  intervention;  besides  it 
deprives  the  body  of  this  part  of  its  protective  system, — 
for  the  glands  act  as  sieves  for  the  infectious  micro-organ- 
isms carried  to  them  by  the  lymphatics. 

In  female  patients  the  cosmetic  effect  of  avoiding  a 
scar  of  some  length  in  the  face  or  in  the  submaxillary  re- 
gion or  on  the  neck  is  often  of  great  importance. 


92  bier's  hyperemic  treatment. 

Case. — Only  girl;  six  years;  scarlet  fever;  severe  ear 
complication;  mastoid  operation  one  side.  Later  repeated 
chills  with  high  fever,  remitting.  Second  operation: 
Exploration  of  sinus.  Soon  large  package  of  inflamed 
lymphatic  glands  behind  maxillary  angle,  in  front,  beneath, 
and  posterior  to  sternocleidomastoid  muscle.  Elastic 
neck-band  promptly  started,  twenty-two  hours  daily; 
warm  wet  dressings.  Temperature  drops;  five  days 
later  beginning  abscess;  ^-inch  incision  in  fold  of  neck; 
small  drainage  tube  for  twelve  hours;  then  removed  and 
regular  suction  treatment  with  glass  cups  added  in  interval, 
i.  e.,  when  neck-band  is  ofT.  Continued  improvement. 
Soon  out  of  bed.  Time  of  head  hyperemia  gradually 
reduced.     Cured.     Scar  hardly  visible. 

Case. — Girl,  five  years.  Acute  tonsillitis  and  naso- 
pharyngitis; normal  course.  Sudden  involvement  of 
glands  beneath  and  posterior  to  sternocleido  muscle. 
High  fever;  threatening  suppuration;  no  tuberculous 
history.  Neck-band  applied  twenty-two  hours  daily; 
child  soon  more  quiet;  motions  of  head  easier;  fever 
drops  to  normal  gradually.  Two  recurrent  attacks  of 
high  temperature.  Hyperemic  treatment  faithfully  con- 
tinued; time  of  application  reduced  by  degrees.  Entire 
glandular  infiltration  becomes  absorbed  within  two  weeks; 
scar  formation  avoided. 

It,  furthermore,  should  not  be  forgotten  that  wounds, 
following  operations  for  acute  or  subacute  lymphadenitis 
in  the  groin  (bubo),  are  often  very  slow  in  healing.  The 
time  of  such  detention  of  these  patients  in  the  wards  of  our 
hospitals  can  often  be  materially  shortened  by  a  correctly 
and  faithfully  conducted  hyperemic  suction  treatment. 

Case. — Boy,  eleven  years.  Large  abscesss  below  Pou- 
part's  ligament  in  Scarpa's  triangle,  due  to  acute  suppu- 


ACUTE    LYMPHADENITIS.       IXFECTED    WOUNDS.  93 

rative  lym])hadenitis.  Cause:  wound  in  sole  of  foot. 
Short  incision,  about  f  inch,  on  top  of  fluctuating 
mass,  in  superficial  anesthesia;  thorough  evacuation  of 
pus;  no  scraping;  no  tamponade;  suction  treatment 
started  four  hours  later ;  continued  regularly.  Entire 
cavity  obliterated  and  boy  discharged  ten  days  later. 

In  infected  wounds  the  aspiration  of  the  secretions  with  Infected 

Wounds, 
suction  glasses  has  shown  excellent  results;   e.  g.,  in  case  of 

a  superficial  or  deep  stitch-hole  abscess  following  an  aseptic 
operation,  no  better  means  for  the  rapid  and  thorough 
cleansing  of  such  a  wound  are  available  than  the  suction  cups. 
Often  the  secretions  stop  after  one  to  two  days'  applica- 
tion, and  the  small  opening  which  had  to  be  made  closes. 

Equally  effective  and  gratifying  is  this  treatment,  of 
course,  in  cases  in  which  some  serum  or  blood  has  accumu- 
lated subcutaneously,  in  perfect  aseptic  healing,  i.  e., 
after  hernia  operations,  appendectomy,  etc.  Perforation 
of  the  thin  part  of  the  scar  with  the  tip  of  a  probe,  gentle 
evacuation  of  the  fluid,  followed  by  regular  daily  use  of 
the  cup,  quickly  bring  the  subcutaneous  tract  or  cavity 
to  a  definite  close,  often  in  as  many  days  as  otherwise 
weeks  are  required. 

Buried  silver  wire  sutures,  or  silver  wire  filigree  implanted 
for  the  closure  of  large,  otherwise  intractable  hernial 
apertures,  that  had  caused  suppuration  in  consequence 
of  localized  fascia-necrosis,  can  usually  remain,  if  the  sinus 
or  sinuses  are  regularly  placed  under  suction-hyperemia. 

A  visible  proof  of  the  disinfecting  power  of  the  cupping 
glass  is  the  fact  that  a  purulent  secretion  from  such  a 
focus  rapidly  becomes  serous. 

The  same  holds  good  in  the  case  of  granulating  wounds 


94  bier's  hyperemic  treatment. 

due  to  infection  (in  spite  of  drainage)  or  fascia  necrosis, 
especially  those  following  abdominal  section  in  fleshy 
patients.  It  is  astonishing  how  much  the  time  required 
for  ultimate  cicatrization  of  such  wounds  can  be  reduced 
by  proper  suction  hyperemia. 
Acute  Infec-         Especially  to  be  mentioned  as  amenable  to  Bier's  treat- 

tious  Inflam- 
mations within  ment  are  the  acute  infectious  inflammations  wdthin  the 
the  Mouth  and 

of  the  Face.  mouth  and  of  the  face  that  are  brought  on  by  the  multi- 
tude of  bacteria  inhabiting  the  oral  cavity:  Inflamma- 
tions of  the  gums  (parulis),  tooth-fistulas,  parotitis, 
phlegmon  of  the  floor  of  the  mouth,  etc.  All  these 
troubles  are  greatly  benefited  by  employing  obstructive 
hyperemia  in  conjunction  with  the  necessary  operation.* 
The  technique  of  the  application  of  the  elastic  bandage 
around  the  neck  has  already  been  fully  described  in  the 
general  part  of  this  book.  The  bandage  remains  in  place 
for  twenty  to  twenty-two  hours  each  day,  in  one  stretch, 
or  twice  ten  to  eleven  hours.  Here,  too,  abscesses  require 
but  a  small  incision,  and  the  pus  can  in  most  cases  be 
aspirated  by  means  of  suction  glasses;  drainage  tubes 
and  gauze  tamponade  are  but  rarely  necessary.  While 
the  patient  may  notice  some  tension  and  increase  of 
swelling  in  the  inflamed  region,  as  a  result  of  the  elastic 
bandage,  the  latter  must  never  cause  sufficient  discomfort 
to  interfere  with  healthy  sleep.     If  he  cannot  sleep  well, 

*  It  would  be  interesting  to  have  dentists  try  to  ascertain  whether 
prolonged  obstructive  hyperemia,  by  means  of  the  elastic  neck-band, 
applied  early,  would  check  the  progress  of  the  thus  far  intractable 
"pyorrhea  alveolaris,"  chronic  suppurative  inflammation  along  the 
alveolar  processes  of  the  jaws,  which  causes  the  teeth  to  become  grad- 
ually loosened  and  ultimately  lost.  Of  course,  the  hyperemic  treat- 
ment could  be  tried  in  addition  to  the  other  local  methods  hitherto 
employed  in  these  cases. 


PARULIS.      PHLEGMON.      TOOTH-FISTULA.      PAROTITIS.  95 

the  bandage  has  been  put  on  too  tight,   and    must  be 

promptly  removed,  to  be  reapphed  more  loosely  after  ten 

minutes.     Every  half-way  intelligent  patient  is  able  to 

regulate  the  degree  of  compression  by  his  own  sensations. 

In  cases  of  beginning  tooth-abscess  and  phlegmon  of  Parulis; 

Phlegmon  of 
the  floor  of  the  mouth,  hyperemic  treatment  will  usually  the  Floor  of  the 

promptly  relieve  the  pain.  Then,  after  incision  of  the 
abscess,  the  continued  congestion  produced  by  the  treat- 
ment makes  the  cavity  close  more  rapidly;  it  also  tends 
to  avoid  bone  necrosis. 

Tooth-fistula  is  best  treated  with  a  suction  glass.  If  Tooth-fistula, 
applied  at  an  early  stage,  this  treatment  may  bring  a 
sinus  to  a  close  without  the  otherwise  resulting  disfiguring, 
funnel-shaped  scar  formation  that  binds  the  soft  tissues 
to  the  bone.  Of  course,  the  cariotic  tooth  or  root  of  tooth, 
as  also  dead  pieces  of  bone,  have  to  be  extracted,  just  the 
same  as  in  any  other  treatment.  But,  under  hyperemia, 
the  small  wound,  which  sometimes  allows  the  probe  to  pass 
right  out  again  through  the  alveolus  into  the  mouth,  can 
be  brought  to  a  permanent  close  with  excellent  cosmetic 
result.  It  is  to  be  hoped  that  with  the  introduction  of 
this  method  the  always  superfluous  but  frequently  advised 
scraping  of  the  bone  for  the  cure  of  a  tooth-fistula  will  at 
last  become  obsolete  and  pass  into  well  deserved  oblivion. 

Case. — Boy,  nine  years ;  tooth-fistula  four  months  ago ;  two 
teeth  extracted;  incision,  and  curettement  of  bone  twice; 
wound  never  healed.  Probe  introduced  appears  in  mouth, 
emerging  at  posterior  end  of  alveolar  process.  Admission  to 
hospital  and  operation  proposed  by  dispensary  surgeon. 
Parents  opposed.  Mother  instructed  in  use  of  suction  cup; 
is  applied  twice  daily  for  half  an  hour.  External  wound  defi- 
nitely closed  after  three,  alveolar  opening  after  five  weeks. 


96  bier's  hyperemic  treatment. 

Parotitis  UniJateral  and  bilateral  parotitis  (mumps)  can  be  cured  by 

(Mumps). 

artificial  hyperemia  "  cito  et  jucunde."     The  pains  promptly 

decrease  and  the  entire  course  is  a  mild  one. 

Metastatic  par-      In  the  well-known  metastatic  form  of  parotitis,  or  those 
otitis.  '  ' 

exceptional  cases  of  acute  parotitis  with  abscess  formation, 

hyperemia  causes  the  glandular  tissue  to  break  down  more 
rapidly,  and  the  resulting  abscess  shows  more  the  char- 
acteristics of  a  cold  abscess.  This  is  opened  by  a  small 
incision  in  a  nonconspicuous  place  under  the  ear  lobe; 
the  wound  heals  without  leaving  any  disfiguring  scar. 

Puerperal  Mastitis. 

After  the  surgeon  has  grasped  the  indication  for  and 
technique  of  suction  hyperemia  and  has  gained  some 
experience  with  the  method  in  minor  surgical  troubles, 
he  will  want  to  try  it  in  diseases  of  greater  magnitude; 
such  as,  for  instance,  puerperal  mastitis. 

It  would  seem  evident  that  if  it  be  true  that  an  infec- 
tious inflammation  without  pus  formation  can  be  success- 
fully dealt  with  by  artificial  hyperemia,  and  if,  further, 
it  be  a  fact  that  by  the  prompt  and  proper  application  of 
hyperemia  pus  formation  can  be  prevented,  then  puerperal 
mastitis  ought  to  furnish  splendid  testing  material  for  the 
truth  of  this  teaching.  And  the  test  has  been  made. 
Numerous  reports  from  obstetrical  clinics  and  obstetricians 
generally  testify  to  the  fact  that  Bier's  treatment  does  all 
it  was  expected  to  do  in  these  cases. 

Hyperemic  treatment  by  suction  promptly  started  and 
carefully  carried  out  as  soon  as  the  first  signs  of  a  puerperal 
mastitis  appeared,  has  saved  a  large  proportion  of  cases 
from  reaching  the  second  stage  of  the  disease;  viz.,  that 
of  suppuration. 


PUERPERAL     MASTITIS. 


97 


It  is  necessary  to  have  various  sizes  of  glasses  on  hand, 
from  which  to  select  the  exact  size  needed.  (See  Figs. 
23  and  24.)  After  the  air  has  been  sufficiently  rarefied, 
the  breast  turns  dark-red  and  is  aspirated  into  the  cup. 
The  patient,  after  being  placed  comfortably  (sitting  on  a 
chair  or  lying  down),  may  herself  hold  the  glass.  (See  Figs. 
68  and  69.)  A  strong  hyperemia  will  evoke  a  sensation  of 
gentle  tension.     Pain  must  never  he  allowed  to  set  in. 


-Shows  the  appHcation  of  the  large  suction  glass  to  the  breast. 
Negative  pressure  is  produced  by  the  suction-pump. 

The  suction  glass  remains  in  place  for  five  minutes  at  a 
time,  followed  by  two  to  three  minutes'  rest,  during  forty- 
five  minutes  each  day.  During  the  remaining  twenty- 
three  and  one-quarter  hours  a  dressing  is  applied  which 
gently  supports  the  breast.  The  pains  usually  decrease 
rapidly  and  refreshing  sleep  returns.  The  fever  disappears 
gradually,  not  suddenly. 
7 


98 


BIER  S   HYPEREMIC    TREATMENT. 


Evacuation  of 
the  Milk. 


The  prompt  evacuation  of  the  milk  from  the  nursing 
breast  is  a  universally  accepted  therapeutic  principle 
in  cases  of  mastitis.  The  retention  of  milk  is  detrimental, 
as  tension  and  pains  are  thereby  increased  and  the  pus 
is  forced  into  the  deeper  strata  of  the  gland. 

If  the  condition  of  the 
nipple  permits,  it  is  best  to 
allow  the  baby  to  continue 
to  nurse,  which  may  be  done 
with  impunity  as  far  as  the 
health  of  the  baby  is  con- 
cerned, for  we  know  that 
the  seat  of  the  inflamma- 
tion is  not  in  the  acini  of 
the  glands  or  the  milk 
ducts,  but  in  the  interstitial 
connective  tissue. 

If  the  baby  cannot  or  is 
not  wanted  to  nurse,  the 
large  glass  cup  used  for 
the  induction  of  hyperemia 
will  usually  do  the  work  of 
evacuating  the  milk.  Often, 
however,  it  may  be  more 
advisable  to  have  a  special 
suction  cup  of  small  size 
placed  over  the  nipple  and  areola — either  before  or  after 
the  hyperemic  treatment — to  act  as  a  milk  pump. 

It  is  wrong,  in  cases  of  puerperal  mastitis,  to  defer 
surgical  intervention  until  distinct  fluctuation  becomes 
manifest. 


Fig.  69. — A  cup  of  smaller  size 
with  rubber  tube  and  bulb.  The 
patient  has  learned  to  manipulate 
it  herself. 


PUERPERAL    :\IASTITIS.  99 

If  the  infiltrated  area  of  the  breast  does  not  diminish  Operative 

Treatment, 
in   size   under   this   treatment   within   twenty-four  hours 

but  keeps  on  increasing,  and  if  a  circumscribed  redness 
of  the  skin  persists,  the  time  has  come  for  incision.  But 
the  incisions  required  in  conjunction  with  hyperemic 
treatment  differ  greatly  from  those  hitherto  employed. 
They  need  not  be  longer  than  three-eighths  of  an  inch 
(one  cm.),  but  must  penetrate  deeply  into  the  infiltrated 
area— into  the  abscess,  if  such  be  present — so  as  to  obtain 
free  exit  for  the  pus.  In  case  of  an  abscess  of  large  size 
a  number  of  such  incisions  should  be  made.  Local  anes- 
thesia with  the  ethyl  chlorid  spray  usually  suffices  to 
insure  freedom  from  pain.  If  deemed  advisable,  infiltra- 
tion anesthesia  may  be  added. 

The  suction  cup  is  applied  right  after  incision,  in  the 
manner  described  above.  The  glass  is  cleansed  of  its 
purulent  and  bloody  contents  during  the  two  to  three 
minutes'  intermission.  Before  starting  the  forty-five 
minutes'  treatment-period  each  day,  careful  examination 
should  be  made  to  see  if  any  new  abscess  or  infiltration 
have  formed.  A  sterile  ointment  dressing  or  a  moist 
dressing  is  placed  over  the  wound  between  the  sittings. 
It  prevents  the  formation  of  crusts  and  can  be  changed 
painlessly.  If  the  borders  of  the  wound  show  great 
tendency  to  become  agglutinated,  the  introduction  of  a 
short  drain  of  small  caliber  may  prove  helpful. 

Any  one  who  has  once  tried  this  treatment  in  mastitis 
must  recognize  its  manifold  advantages.  It  is  painless, 
prompt  in  its  action  and  leaves  no  ugly,  disfiguring  scars. 
The  contours  and  function  of  the  breast  are  fully  preserved. 

Obstetricians  distinguish  between  mastitis  due  to  ob- 


100  bier's  hyperemic  treatment. 

struction  and  that  caused  by  an  infection.  The  former 
always  yields  nicely  to  hyperemic  treatment.  The  latter, 
and  more  frequent  type,  either  tends  to  localization  with 
abscess  formation,  or  is  of  progressive  character,  similar 
to  the  phlegmon  of  the  extremities. 

Here  the  surgeon's  work  again  lies  along  the  border- 
land between  conservative  and  radical  procedure.  If 
the  patient  is  anxious  to  have  the  breast  preserved 
in  its  shape,  function  and  appearance,  the  surgeon  may 
well  continue  the  suction  treatment,  even  if  he  has 
to  lance  as  many  as  six  to  seven  abscesses  in  the 
course  of  the  treatment.  The  result  will,  in  most 
'instances,  amply  repay  both  patient  and  surgeon  for  the 
trouble  and  time  bestowed  upon  the  treatment. 

If,  on  the  other  hand,  the  aforementioned  considerations 
are  not  of  importance,  if  the  patient  does  not  care,  and  the 
surgeon  feels  that  he  has  not  the  time  or  facilities  for. the 
proper  carrying-out  of  the  treatment,  it  is  well  that  he 
should  proceed  according  to  former  methods,  i.  e.,  long 
incisions  plus  drainage.  He  should  bear  in  mind,  however, 
that  in  severe  cases  of  phlegmonous  mastitis  repeated 
incisions  may  also  become  necessary  in  the  course  of  the 
after-treatment,  and  thus  there  may  be  no  saving  of  time 
after  all.  Surely,  we  all  know  of  cases  in  which  it  took 
many  long  and  tedious  weeks  before  ultimate  cicatrization 
set  in. 

We  have  found  two  cases  recorded,  in  which  persistent 
adherence  to  the  suction  treatment  is  said  to  have  necessi- 
tated amputation  of  the  breast.  At  Bier's  clinic,  however, 
where  upward  of  sixty  cases  of  mastitis,  including  the 


INFLAMMATION  OF  JOINTS  (ARTHRITIS  GONORRHCEICA).  101 

severest  types,  were  treated,  no  such  experience  has  been 
had;  all  were  cured  by  suction  hyperemia. 

Acute  Infectious  Inflammation  of  Joints  (Arthritis 
Gonorrhoeica)  . 

Thus  far  the  principles  of  artificial  hyperemic  treatment  Joint  Infec- 
have   been   discussed   with    reference    to    acute   bacterial 
surgical    infections,    located    superficially.     The    effect    of 
this  powerful  therapeutic  agent  was  visible;    it  could  be 
easily  controlled  and  the  various  phases  studied. 

The  beginner  will  do  well  to  gain  his  first  experience 
with  this  class  of  cases.  The  treatment  of  articular 
infectious  inflammations  by  artificial  hyperemia  involves 
far  greater  responsibility.  Lasting  stiffness  of  the  joints 
(ankylosis)  and  general  sepsis  are  the  dreaded  sequelae 
to  be  guarded  against. 

A  strict  and  refined  diagnosis  is  the  first  postulate;  the 
ability  to  carry  out  any  major  operation  that  may  become 
necessary,  the  second. 

In  spite  of  the  fact  that  hyperemic  treatment  of  the 
infected  joints  is  by  no  means  an  easy  matter,  it  is  never- 
theless highly  recommended,  for  its  results  with  proper 
technique  are  excellent. 

To  the  category  of  acutely  infected  joints  belong: 

1.  Joints  in  which  the  infection  is  the  result  of  a  trauma-  Indication. 
tism. 

2.  Metastatic  empyema  of  the  joints,  as  observed  in 
connection  with  acute  osteomyelitis,  etc. 

3.  Acute  gonorrheic  inflammation  of  serious  character. 

Bier  teaches  that  such  joints  should  be  promptly  sub- 
jected to  obstructive  hyperemia.  The  sooner  after  the 
onset  of  the  articular  pains  the  elastic  bandage  is  applied. 


102 


BIER  S    HYPEREMIC   TREATMENT, 


Technique. 


Movements  of 

Inflamed 

Joints. 


the  better  will  be  the  result  obtamed.  In  eases  in  which  the 
treatment  is  started  within  the  first  few  hours  after  the  pain 
sets  in,  the  improvement  often  is  so  rapid  and  striking  that 
the  correctness  of  the  diagnosis  may  be  questioned. 

Time  of  treatment,  twice  ten  to  eleven  hours  per  day. 
In  the  interval,  elevation  of  the  limb  in  order  to  reduce  the 
edema.  Signs  indicating  a  favorable  effect  of  the  treat- 
ment :  decrease  of  pain,  increased  mobility. 

With  a  correct  technique,  the  pain  present  in  an  acutely 
infected  joint  will  be  relieved  within  a  few  hours.  This 
rapid  abatement  of  the  pain  as  the  obstructive  hyperemia 
becomes  more  pronounced  must  convince  even  the  most 
skeptical  of  the  great  truth  underlying  Bier's  teachings; 
namely,  that  by  artificially  increasing  the  symptoms  of 
inflammation  we  hasten  its  cure. 

This  release  from  pain — priceless  boon  to  the  patient — 
is  doubly  welcome  to  the  attending  surgeon,  inasmuch  as 
it  renders  possible  gentle  active  and  passive  motions.  For 
a  fundamentally  new  factor  in  our  therapeutics,  that  has 
followed  in  the  trail  of  hyperemic  treatment,  is  the  recog- 
nition of  the  fallacy  of  the  old  idea  of  immobilizing  these 
joints  as  long  as  possible.  Such  practice  is  productive  of 
stiffening,  the  very  condition  which  it  is  our  aim  to  avoid. 
As  soon  as  the  pains  have  been  sufficiently  relieved  to  make 
it  possible,  the  patient  is  instructed  to  gently  move  the 
affected  joint.  These  passive  exercises  are  harmless,  as 
long  as  they  cause  no  pain. 

While  the  treatment  by  means  of  obstructive  hyperemia 
makes  greater  demands  upon  the  skill  of  the  surgeon  than 
the  practice  of  incision  plus  drainage  followed  by  fixation 
of  the  joints,  the  result  amply  rewards  him  for  his  pains. 


IXFLAM.MATIOX  OF  JOINTS  (ARTHRITIS  GOXORRHCEICa).  103 

Case. — Physician,  athlete,  sustains  compound  disloca- 
tion of  interphalangeal  joint  of  right  thumb  while  wrestling 
in  gymnasium.  Innnediate  reduction.  No  aseptic  dress- 
ing— in  accordance  with  usual  personal  carelessness  of 
physicians.  Soon  joint  suppuration.  Acute  osteo-perios- 
titis  of  both  phalanges.  Pronounced  local  swelling. 
Lymphangitis;  fever.  Admission  to  hospital.  Two  lateral 
incisions  into  joint,  several  over  phalanges,  down  to  bone, 
avoiding  tendons.  Xo  drainage;  prompt  careful  hyper- 
emic  treatment,  bandage  around  arm  twenty-two  hours 
out  of  twentA'-four.  Improvement.  Gradual  reduction 
in  time  of  application  of  bandage;  leaves  hospital  ten 
days  later.  Two  small  sequestra  are  discharged.  Per- 
fect functional  result ;  no  ankylosis. 

The  rule  to  always  carefully  examine  into  the  exact  Evacuation  of 
condition  of  affairs  during  the  interval,  after  the  edema  has 
sufficiently  decreased,  applies  also  to  these  cases  of  infec- 
tious joint  disease.  Exploratory  puncture  must  be  ex- 
tensively practised.  Just  as  soon  as  pus  or  a  sero-purulent 
exudate  is  discovered,  the  joint  should  be  punctured  with 
a  large  needle  or  trocar  and  then  irrigated. 

Saline  solution  is  the  best  for  this  purpose,  although  Irrigarion  of 

the  Joints. 

weak  antiseptic  lotions  may  also  be  employed.  The  use 
of  carbolic  acid  solution  or  any  other  strongly  disinfecting 
chemical  is  advised  against,  as  they  might  destroy  the 
synovial  membrane.  It  is  not  a  disinfection  of  the  syno- 
vial sac  that  is  required,  but  merely  a  mechanical  removal 
of  the  purulent  fluid.  This  irrigation  of  the  joint  may  be 
repeated  for  short  periods  daily,  if  necessary.  Serous  or 
slightly  turbid  fluid  usually  disappears  under  hyperemic 
treatment  without  irrigation.  Bacterial  examinations  of 
the  exudate  will  show  a  gradual  decrease  of  the  bacilli; 
the  turbid  evacuation  becomes  clear— serous. 


104 


BIER  S    HYPEREMIC   TREATMENT. 


Arthrotomy 
with  Drainage 
Last  Resort 


Arthrotomy  with  drainage  is  done  only  as  a  last  resort; 
{.  e.,  if  no  improvement  is  seen  under  hyperemic  treatment. 
It  should  be  deferred  as  long  as  possible,  as  ankylosis 
usually  follows. 

If  ever,  then  here  experience  and  tact  on  the  part  of  the 
attending  surgeon  are  required. 

The  curative  effect  of  hyperemic  treatment  in  the  case 
of  infected  joints,  or  other  deep-seated  infected  foci,  proves 
its  bactericidal  power. 

It  will  be  interesting,  whenever  it  can  be  conveniently 
done,  to  have  a  bacteriologic  examination  made  of  the 
fluid  withdrawn  from  the  joint  before  and  after  the  hyper- 
emic treatment. 

Case,  proving  that  hyperemic  treatment  alone  can  over- 
come infectious  joint  inflammation:  Man,  forty-eight 
years;  sustains  transverse  patellar  fracture;  no  complicat- 
ing wound  or  skin  abrasion;  pronounced hemarthros.  Hot- 
air  treatment.  On  eighth  day  increasing  fever;  beginning 
suppuration.  Aspiration  shows  sero-purulent  exudate; 
staphylococcus  in  pure  culture.  Hyperemic  treatment  im- 
mediately started,  twenty  hours  daily.  Extremity  sup- 
ported by  pillows.  Marked  edema;  reduced  slightly  during 
intervals.  General  condition  and  inflammatory  symptoms 
soon  improve.  Gentle  passive  motions  begun  at  end  of 
first  week  of  treatment.  Temperature  drops  steadily;  is 
normal  on  twelfth  day.  Aspiration  needle  now  draws 
sterile  hemorrhagic  serum.  Swelling  has  entirely  sub- 
sided after  three  weeks;  good  active  and  passive  mobility. 
Artificial  hyperemia  discontinued.  Hot-air  treatment. 
Discharged  after  another  three  weeks  with  good  function. 


Perforative 
Woxmds  of  the 

Joints.  loose  aseptic  dressing 


Perforative  wounds  of  the  joints  are  covered  with  a 
Secretion  will  be  much  increased 
under  artificial  hyperemia. 


FELON  AND  PHLEGMON  OF  TENDON-SHEATHS.    105 

In  the  event  of  a  periarticular  abscess,  the  same  is 
opened  by  means  of  a  small  incision  and  aspirated  with  a 
suction  glass  for  three-quarters  of  an  hour  each  day;  i.  e. 
the  usual  six  applications  of  five  minutes  each,  with  inter- 
missions of  two  to  three  minutes. 

It  hardly  needs  special  mention,  that  the  fever  gradually  Fever, 
disappears  under  this  conservative  regime. 

The  treatment  is  continued  for  twenty  to  twenty-two  Treatment, 
hours  daily,  until  the  temperature  has  become  normal, 
after  which  it  is  shortened  by  two  hours  each  day.  After 
about  ten  days  it  usually  can  be  stopped  altogether. 
Should  the  fever  and  pains  increase  again  during  this  period 
of  gradually  lessened  time  of  application,  the  number  of 
hours  must  be  increased  again. 

Under  such  abortive  treatment  of  an  acute  articular 
infection,  pain  and  fever  may  cease  within  three  to  four 
days,  and  a  complete  return  to  normal  conditions  set  in 
within  ten  to  fourteen  days.  This  is  true  principally  in 
cases  of  acute  gonorrheic  infection. 

Felon  and  Phlegmon  of  the  Tendon-Sheaths. 

Felons  and  the  phlegmon  of  the  tendon-sheaths  are 
pathologically  closely  affiliated.  They  will,  therefore,  be 
considered  in  the  same  chapter. 

Felons  can  be  successfully  treated  by  hyperemia  by  Felon  (Panari- 
means  of  the  elastic  bandage,  the  latter  to  remain  in  place 
for  twice  ten  to  eleven  hours  or  for  twenty  to  twenty-two 
hours  per  day  without  interruption.  However,  the 
application  of  the  suction  glass  designed  for  the  finger 
(Fig.  34)  is  preferable,  and  if  applied  early  may  nip  the 
trouble  in  the  bud. 


106 


BIERS    HYPEREMIC   TREATMENT, 


Technique. 


Incision. 


Dressing. 


A  finger-cot  is  pulled  over  the  entrance  hole  of  the  cup; 
then  sufficient  of  the  tip  is  cut  off  to  make  the  inflamed 
finger  fit  in  the  aperture.  In  this  way  one  cup  will  do  for 
all  sizes  of  fingers,  and  there  will  be  no  constriction  at  the 
base.  A  true  suction  hyperemia  is  thus  produced.  Rare- 
faction of  the  air  within  the  cup  is  effected  by  a  rubber 
bulb  which  the  patient  operates  himself;  or  a  suction 
pump  may  be  employed,  which  requires  an  assistant. 
A  red  hyperemia  is  desired;  too  strong  suction  is  apt  to  do 
harm. 

In  the  ordinary  case  it  is  best  to  make  a  short  incision, 
even  if  no  pus  is  encountered  as  yet,  and  then  inmiediately 
apply  the  cup.     Retention  of  pus  must  never  set  in. 

The  wound  is  covered  w^ith  an  ointment  or  with  a  wet 
dressing,  which  prevents  its  borders  from  becoming  glued 
together.  Tampons  are  never  used,  nor  are  prolonged 
hand-baths  ordered,  as  they  macerate  the  skin  too  much. 
Only  now  and  then  a  hand-bath  is  given  for  the  sake  of 
cleanliness.     Fixation  splints  are  superfluous. 

Careful  observation  is  necessary  to  ascertain  whether 
the  process  is  a  progressive  one,  and  whether  the  sheaths 
of  the  tendons  remain  uninvolved. 

Early  and  properly  applied  hyperemia  may  avoid 
necrosis  of  the  phalanges. 

In  case  of  a  subcutaneous  felon  in  which  the  function 
of  a  tendon  or  joint  are  not  at  stake,  free  incision  done 
painlessly  under  proper  cocainization,  followed  by  tampon- 
ade will  deal  more  simply  with  the  trouble  and,  at  the  same 
time,  constitute  radical  treatment.  By  previously  moisten- 
ing the  tampon  with  peroxide  the  pain  otherwise  connected 
with  the  removal  of  the  same  may  also  be  spared  the  patient. 


FELON    AND    PHLEGMON    OF   TENDON-SHEATHS.  107 

The  necrosis  of  the  soft  parts,  so  frequently  seen  in 
these  cases,  can  be  more  speedily  overcome,  if  not  alto- 
gether avoided,  by  following  up  the  above  procedure  by  a 
course  of  obstructive  hyperemia,  or  perhaps,  better  still, 
suction  hyperemia.  Then,  of  course,  the  tampon  must  be 
omitted. 

For  those  patients  who  are  afraid  of  the  knife,  or  those 

for  whom  it  is  of  paramount  importance  to  preserve  the 

normal  shape  of  the  finger-tip,  e.  g.,  pianists,  hyperemic 

treatment,  employed  in  the  beginning  of  the  inflammation, 

also  holds  out  the  possibility  of  a  cure,  though  with  more 

sacrifice  of  time. 

The  hyperemic  treatment  of  phlegmon  of  the  sheaths  Phlegmon  of 
•^  ^  I        c  jjjg  Tendon- 

of  the  tendons  is  one  of  the  most  difficult  and,  at  the  same  sheaths, 
time,   most  important   tasks   of   the   surgeon.     Here   the 
new  teaching  of  Bier  is  put  to  the  test  as  to  its    ability 
to  master  serious  infections. 

So  far,  the  principle  of  modern  surgery  in  treating 
this  kind  of  cases  has  been : 

1.  Elevation — to  oppose  venous  stasis — with  its  subse- 
quent interference  with  proper  nutrition  (necrosis).  2,  Free 
incision,  so  as  to  give  unobstructed  exit  to  the  bacteria  and 
their  toxins,  in  conjunction  with  proper  drainage.  3.  Rest 
of  the  affected  part,  in  order  to  prevent  involvement  of  the 
adjacent  tissues.  4.  No  mechanical  insult  to  the  protective 
wall,  furnished  by  the  granulating  wound. 

This  treatment  often  ended  with  necrosis  of  the  tendon  or 
tendons,  with  impeded  motion,  or  entire  loss  of  function 
of  fingers  or  hand,  in  spite  of  most  careful  surgical  super- 
vision. 

The  results  of  Bier's  hyperemic  method  are  more  satis- 


108  bier's  hyperemic  treatment. 

factory.     The  tendon  and  its  function  are  usually  pre- 
served. 
The  rules  for  the  accomplishment  of  this  purpose  are: 

1.  Obstructive  hyperemia,  bringing  more  blood  to  the 
spot  where  the  fight  goes  on,  in  order  to  aid  the  system 
in  its  endeavor  to  overcome  the  invading  foe. 

2.  Small  multiple  incisions,  without  drainage. 

3.  Gentle  pressing  of  the  parts  toward  the  incision,  to 
facilitate  the  evacuation  of  the  pus. 

4.  Early  active  and  passive  motions,  to  guard  against 
the  threatening  stiffening. 

In  other  words,  the  formerly  generally  accepted  and  prac- 
tised radical  procedure  is  transformed  into  a  conservative  one. 

This  does  not  mean,  however,  that  now  the  general 
practitioner  is  expected  to  take  care  of  these  patients, 
in  whom  the  question  of  the  proper  functioning  of  a  most 
important  part  of  the  human  body — at  least  as  far  as  the 
working-classes  are  concerned — often  even  their  very 
life,  is  at  stake.  No;  now,  as  before,  these  patients  belong 
to  the  hospital.  They  should  be  placed  under  the  most 
rigid  permanent  observation,  and  in  a  place  where,  if 
occasion  arises,  the  necessary  operation  can  be  promptly 
performed.  This  point  cannot  be  too  strongly  emphasized. 
Technique.  "YhQ  physician  who  sees  a  case  of  this  kind  in  the  beginning 

of  the  infection,  shortly  after  the  injury  was  sustained, 
can  prevent  the  development  of  an  infectious  inflammation 
by  promptly  arranging  for  obstructive  hyperemia,  for 
twenty  to  twenty-two  hours  per  day. 

The  anatomic  changes  at  this  stage  of  the  disease  are 
hyperemia  of  the  sheaths  of  the  tendons  and  exudation 
of  turbid  serum. 


FELOX   AND    PHLEGMON    OF   TENDON-SHEATHS.  109 

Of  course,  most  careful  examination  of  such  recent  cases 
is  imperative.  If  tenderness  along  the  course  of  the  re- 
spective tendon,  impeded  function,  fever  and  general 
malaise  are  present,  it  must  be  assumed  that  pus  has 
already  formed,  and  such  pus  must  have  a  prompt  exit. 

It  is  generally  recognized  that  this  disease  is  of  graver 

consequences  at  the  hand  than  at  the  foot,  and  more 

serious  at  the  volar,  than  at   the   dorsal,  aspect   of  the 

hand. 

Anatomy  teaches   that   the   second,   third  and  fourth  Anatomic  De- 
scription, 
fingers  have  double  sheaths  for  their  flexor  tendons.    The 

distal  one  extends  from  the  tip  of  the  finger  to  about  its 
base.  (Fig.  70,  a,  a,  a.)  They  have  no  intercommunica- 
tion with  one  another,  nor  with  the  large  synovial  sac  in 
the  palm  of  the  hand.  The  fifth  (small)  finger  makes  an 
exception.  The  continuation  of  its  synovial  membrane 
is  the  large  hour-glass-shaped  sac  (Fig.  70,  b)  crossed  by 
the  transverse  ligament  at  the  wrist.  (Fig.  70,  /.)  The 
thumb  has  a  long  sheath  of  its  own  for  its  flexor  tendons. 
It  passes  underneath  the  transverse  ligament,  and  usually 
does  not  connect  with  the  large  synovial  palmar  sac,  but 
is  immediately  adjacent  to  it.  (Fig.  70,  c.)  The  tendon 
of  the  flexor  carpi  radialis  muscle  has  a  special,  short 
sheath,  right  in  front  of  its  insertion  at  the  base  of  the 
second  metacarpal  bone.     (Fig.  70,  d.) 

For  a  short  time  an  acute  infectious  inflammation  re-  Advance  of  the 
1  •     1        1      T  rrti  1  -11      Infectious  Pro- 

spects the  anatomic  border  Ime.     Ihen,  however,  it  breaks  cess. 

through  the  same  and  inundates  the  surrounding  con- 
nective tissue,  at  times  also  extending  to  the  neighboring 
tendon-sheaths. 


110 


BIER  S    HYPERE.MIC    TREATMENT. 


»/»....,,.,  /W 


Fig.  70. — Illustrates  the  anatomy  of  the  palm  of  the  hand  with 
especial  reference  to  the  synovial  sacs  of  the  tendon-sheaths,  a.  a,  a. 
Show  the  lower  end  of  the  peripheric  sheath  for  the  second,  third,  and 
fourth  finger,  b,  The  large  palmar  sac,  through  which  run  the  flexor 
tendons  of  the  second,  third,  fourth,  and  fifth  finger.  It  is  crossed  by 
the  broad  transverse  ligament,  /,  the  latter  rendering  it  hour-glass 
shaped.  The  flexor  sheath  of  the  small  finger  communicates  with  this 
directly;  therefore,  injuries  to  the  same  are  most  dangerous,  c.  Shows 
the  flexor  sheath  of  the  thumb,  the  lower  horizontal  line  leading  to 
the  close  proximity  of  the  same  to  the  large  palmar  bursa  itself,  d, 
Points  to  the  sheath  of  the  flexor  carpi  radialis  which  not  infrequently 
becomes  infected  in  connection  with  inflammation  of  the  other  flexor 
sheaths,  e,  e,  Indicate  the  transverse  volar  ligaments  of  the  fingers, 
which  should  be  most  carefully  avoided  when  operating.  A  long 
incision,  from  the  tip  of  the  finger  toward  the  palm,  as  practised  by 
many,  naturally  divides  the  same,  thereby  permitting  the  tendon  to 
leave  its  normal  place,  which  usually  means  death  to  the  tendon. 


FELON   AND    PHLEGMON    OF   TENDON-SHEATHS. 


Ill 


The  rapid  progress  of  a  virulent  infection  of  the  fifth 
finger  to  the  large  palmar  sac,  thence  to  the  flexor  sheath 
of  the  thumb,  and  finally  to  the  wrist-joint  and  the  inter- 
stices of  the  muscles  of  the  forearm,  is  a  well-known 
clinical  picture. 


Fig.  71. — Shows  Klapp's  method  of  incising  an  infected  sheath  of 
the  flexor  tendons  of  the  hand  and  forearm.  Note  the  double  row  of 
incisions  on  either  side  of  the  finger  tendon  from  the  base  to  the  third 
phalanx.  The  tissues  in  the  middle  line  of  the  finger  remain  undis- 
turbed and  protect  the  tendon  against  exposure. 

The  inflammatory  exudate  within  the  extremely  tense 
connective  tissue  of  the  palm  of  the  hand  soon  becomes 
subjected  to  a  high  degree  of  pressure,  which,  in  turn, 
pushes'l^on  the  infectious  process  and  produces  the  con- 


112  bier's  hyperemic  treatment. 

comitant  edema  of  the  dorsal  aspect  of  hands  and  fingers, 
which  so  often  is  mistaken  for  a  phlegmon  of  the  dorsum. 
Incision.  ^y   accumulation   of   pus   needs   prompt   evacuation. 

Short  incisions  are  to  be  made  wherever  the  presence  of 
pus  is  suspected,  also  outside  of  the  sheaths;  i.  e.,  into  the 
surrounding  connective  tissue.  Care  must  be  taken  not 
to  injure  the  transverse  ligaments  at  the  fingers  (Fig. 
70,  e),  since  the  division  of  these,  as  is  well  known,  usually 
means  loss  of  the  tendon.  They  must,  therefore,  be  pre- 
served at  all  hazards,  a  rule  which  has  always  been  observed 
by  careful  surgeons.     (Fig.  72.) 

•  Regarding  the  size  of  the  incisions,  they  have  learned 
at  Bier's  clinic  to  get  along  with  comparatively  small 
cuts.  However,  the  surgeon  who  has  not  yet  had  very 
much  experience  with  the  method,  may  prefer  a  wider 
exit  for  the  infected  exudate  and  woimd  secretions,  to 
which  there  is  no  objection  other  than  that  the  resulting 
scars  will  be  longer. 

The  infected  sheath  is  best  opened  over  the  volar  aspect 
of  the  metacarpo-phalangeal  joint  and  that  of  each  phalanx, 
by  a  double  incision,  at  either  side  of  the  tendon.  (Klapp.) 
(See  Fig.  71.)  It  is  thoroughly  relieved  of  its  contents 
by  gentle  pressure  of  the  soft  parts.  The  cuts  furnish 
free  drainage  during  the  after-treatment,  inasmuch  as 
they  gape  when  the  fingers  are  flexed:  they  do  not  allow 
the  tendon  to  become  exposed  anywhere.  The  latter 
always  remains  covered  by  the  natural  tissues,  as  shown 
by  the  illustration. 

For  the  palmar  sac  two  openings  above  and  two  below 
the  transverse  ligament  usually  suffice;  two  more  enter 
the  proximal  part  of  the  flexor  sheath  of  the  thumb  and 


FELOX   AND    PHLEGMON    OF   TEXDOX-SHEATHS. 


113 


extensor  carpi  radialis  in  severe  cases.  Otherwise  the 
number  of  incisions  corresponds  to  the  extent  of  the  inflam- 
mation. 

This  operation  is  preferable  to  that  frequently  practised, 
with  the  skin  incision  in  the  middle  line  of  the  finger  directly 
over  the  sheath  (see  Fig.  72)  and  opening  of  the  latter 
in  a  somewhat  lateral  direction. 


Fig.  72. — Shows  where  the  multiple  incisions  should  best  be  made  in  case 
of  suppuration  within  the  tendon-sheaths  of  the  volar  flexors. 

Gauze  tamponade  or  drainage  with  tubes  is  not  employed.  Dressing. 
For  a  few  hours  (two  or  three)  a  gently  and  lightly  com- 
pressing dressing  is  applied.     When  the  danger  of  hemor- 
rhage has  passed,  this  dressing  is  changed  for  an  aseptic 
towel,  folded  loosely  around  the  dressings  covering  the 

Af  t6r~trc3.t"' 
hand  (see  Fig.  4),  and  obstructive  hyperemia  is  started  ment. 


114  bier's  hyperemic  treatment. 

with  the  elastic  bandage  around  the  arm  for  twenty  to 
twenty-one  out  of  the  twenty-four  hours.  Before  reapply- 
ing the  bandage,  the  parts  must  be  carefully  examined 
to  see  if  the  infection  has  spread  further,  in  which  event 
additional  incisions  should  be  immediately  made. 

During  the  intervals,  the  arm  is  elevated,  in  order  to 
reduce  the  edema. 

The  tendons  are  not  exposed  during  the  treatment; 
they  remain  covered  by  the  soft  parts  and  are  bathed  by 
the  continuous  current  of  serum  that  finds  its  exit  through 
the  incisions.  All  this  tends  to  save  the  tendon  from 
necrosis.  The  incisions  do  not  usually  heal  before  the 
virulent  stage  of  the  infection  has  passed.  Should  scabs 
form  nevertheless,  they  have  to  be  removed  either  with 
dressing  forceps  or  by  means  of  a  warm  hand-bath. 

The  time  of  application  of  the  band  is  reduced  by  two 
hours  each  day,  as  soon  as  the  temperature  has  subsided 
and  the  more  serious  symptoms  have  disappeared. 

During  the  entire  course  of  the  treatment,  gentle  active 
exercises  with  the  fingers  are  insisted  upon;  passive  mo- 
tions are  carefully  made  by  the  surgeon  whenever  the 
dressing  is  changed.  This  will  prevent  the  formation  of 
adhesions  between  the  tendons  and  their  sheaths. 

These  cases,  if  treated  early  in  accordance  with  the 
principles  laid  down  by  Bier,  will  usually  come  out  with 
the  tendons  preserved. 

More  advanced  cases,  with  suppuration  of  several  days' 
standing,  inside  and  outside  of  the  tendon-sheaths,  often 
showing  the  tendons  in  beginning  necrosis,  cannot,  of 
course,  be  fully  restored,  even  by  the  most  carefully  con- 
ducted hyperemic  treatment.    Yet,  if  promptly  started, 


FELOX    AXD    PHLEGMOX    OF   TEXDOX-SHEATHS. 


115 


if  may  often  still  succeed  in  maintaining  the  function  of 
the  finger  to  some  extent  at  least.  In  these  advanced 
cases  it  is  wise  to  make  the  incisions  somewhat  longer. 
(Fig.  73.) 


Fig.  73. — Shows  a  severe  phlegmon  of  the  hand  and  forearm.  The 
second  phalanx  of  the  thumb  was  lost  in  consequence  of  a  subperiosteal 
felon  with  subsequent  necrosis.  With  the  help  of  incisions  in  the  palm 
of  the  hand  and  volar  aspect  of  the  forearm,  the  patient  was  cured 
with  good  function. 

In  the  cases  seen  early  the  first  few  days  of  treatment 
will  determine  the  life  or  death  of  the  tendon.  Most 
careful  observation,  strict  diagnosis  regarding  the  possible 


116  bier's  hyperemic  treatment. 

further  accumulation  of  pus,  which  then  requires  prompt 
additional  incisions,  and  intelligent  criticism  are  essential 
to  good  work.  We  know  how  often  a  virulent  progressive 
infection  of  the  sheaths  invades  first  the  joints  of  the 
fingers,  then  of  the  carpus  and  finally  extends  to  the  wrist. 
These  complications  must  be  recognized  in  time,  and  the 
inflamed  joints  incise^  and  then  promptly  treated. 

The  usually  resulting  stiffness  may  be  mobilized  by  hot- 
air  treatment  and  expert  massage. 

In  few  surgical  diseases  is  an  early  and  correct  diagnosis 
of  more  importance  than  in  acute  inflammation  of  the 
flexor  tendon-sheaths.  In  few  will  the  early  careful  appli- 
cation of  hyperemia  do  more  good  in  a  preventive  way. 
Months  of  suffering  can  thereby  be  spared  the  patient, 
and  endless  worry  and  deprivation  to  a  workman's  family. 
It  is  a  triumph  to  have  such  a  patient  come  out  with 
movable  fingers  and  a  useful  hand. 

It  is  true,  a  certain  percentage  will  have  perfect  function 
also  when  treated  after  the  manner  so  far  in  vogue,  but 
after  how  many  weeks  of  painful  operative  work  and 
after-treatment,  surgical  and  mechanical ! 

Bier's  hyperemia  if  started  early,  can  accomplish  this 
with  little  pain  and  discomfort  to  the  patient  and  in  con- 
siderably less  time.  Of  course,  in  cases  in  which  the  disease 
has  made  much  headway,  in  which  venous  stasis  with 
thrombosis  of  the  veins  and  beginning  necrosis  have 
set  in,  artificial  hyperemia  is  also  helpless.  It  may  hasten 
the  process  by  a  more  rapid  pus  formation;  it  may  facili- 
tate the  secretion;  it  may  at  best  save  a  part  of  the  tendon 
if  the  whole  was  not  doomed  from  the  start;  but  it  cannot 
restore  life  to  dead  parts. 


FELON  AXD  PHLEGMON  OF  TENDON-SHEATHS.    117 

Therefore,  let  the  general  practitioner,  who  usually 
sees  these  cases  first,  remember  that  here  hours  count; 
let  him  make  it  his  business  to  study  and  master  the  essen- 
tials of  the  method;  let  him  act  promptly  and  send  the 
patient,  with  the  elastic  bandage  properly  around  the  arm, 
to  a  hospital.  For  these  cases  are  hospital  cases  and  need 
careful  attention  by  expert  surgeons,  until  the  infection 
has  been  brought  under  control. 

Exceptionally,  a  few  short  incisions  into  an  infected 
tendon-sheath  prior  to  starting  the  hyperemic  treatment 
prophylactically ,  may  become  advisable,  especially  in  cases 
of  streptococcus  infection.  For  it  seems  necessary,  in  the 
very  virulent  cases  at  least,  that  the  serous  exudation 
promptly  produced  by  the  infectious  process  plus  the  serum 
engendered  as  a  result  of  the  prolonged  application  of  the 
elastic  bandage,  have  an  outlet  from  the  closed  sac  that 
we  call  the  tendon-sheath. 

It  certainly  is  possible  that  infectious  inflammations 
exist  in  which  primary  obstructive  hyperemia,  viz., 
increased  inflammation,  without  'providing  for  an  outlet 
of  the  inflammatory  exudate,  can  do  harm. 

In  view  of  our  inability  to  determine  the  species  of  cocci 
which  is  responsible  for  the  acute  tenosynovitis  without  . 
having  opened  the  sheath  of  tendon,  further  experience  may 
show  it  to  be  advisable  to  make  primary  incisions  into  the 
sheath  in  every  instance. 

In  order  to  establish  more  exact  lines  as  to  which  of  the 
great  variety  of  this  class  of  cases  can  be  principally  bene- 
fited by  artificial  hyperemia,  it  has  been  recommended 
to  have  a  primary  bacteriologic  examination  made,  espe- 
cially in  cases  in  which  there  is  no  open  wound,  or  those 
that  have  not  received  surgical  treatment  elsewhere. 


118  bier's  hyperemic  treatment. 

In  cases  in  which  the  preservation  of  a  tendon  or  joint 
is  not  at  stake — e.  g.,  in  a  case  of  subcutaneous  phlegmon 
of  the  arm,  with  or  without  fascia-necrosis — it  may  not  be 
worth  the  trouble  and  worry  to  try  artificial  hyperemia. 
A  number  of  good-sized  incisions,  and  drainage  with 
tubes  for  a  few  days — in  other  words,  the  old  method  of 
treatment — ^will  usually  effect  a  cure.  Those  who  have 
acquired  sufficient  experience  with  Bier's  treatment  may 
add  obstructive  hyperemia.  However,  just  in  these  cases 
there  seems  to  be  great  tendency  to  skin-necrosis.  Hence 
the  advisability  of  here  applying  hyperemia  still  remains 
a  mooted  question. 

"  On  the  other  hand,  lymphangitis  and  erysipelas,  which 
may  follow  our  surgical  work  in  streptococcous  infection, 
are  often  successfully  dealt  with  by  the  obstructing  elastic 
band.  Nevertheless  an  erysipelatous  reddening  has  often 
been  seen  to  advance  up  to  the  elastic  bandage,  but  it  was 
usually  much  less  virulent  than  the  ordinary  erysipelas. 

In  view  of  the  facts  stated,  it  wUl  simplify  the  work  in 
our  hospitals  if  cases  of  subcutaneous  phlegmon  are  treated 
as  before.  A  laborer  does  not  care  whether  his  incisions  are 
three  to  four  or  one  inch  long.  However,  when  it  comes  to 
a  young  woman  of  society,  conditions  are  different.  Here  the 
cosmetic  result  may  be  of  great  importance,  and  it  is  com- 
forting in  such  a  case  to  know  a  method  of  treatment  which, 
although  requiring  continuous  great  care  and  attention, 
may  accomplish  a  cure  with  very  little  disfigurement. 

Acute  Osteomyelitis. 

Acute  Osteo-  The   experience   gathered  with   obstructive  hyperemia 

myelitis. 

in  acute  surgical  infections  of  the  soft  tissues  invited  a 


ACUTE    OSTEO:\IYELITIS.  119 

test  of  its  bactericidal  effect  also  in  the  acute  suppurative 
inflammation  of  the  bone-marrow — in  acute  osteomyelitis. 

There  can  be  no  doubt  that  in  cases  in  which  obstructive 
hyperemia  is  applied  early  and  faithfully  for  twenty  to 
twenty-two  hours  per  day,  a  beginning  conflagration 
can  be  extinguished,  although  it  is  well-nigh  impossible 
in  these  cases  to  prove  that  the  diagnosis  was  correct  after 
the  symptoms  have  subsided.  It  is,  however,  but  logical 
to  assume  that  in  this  affection,  same  as  in  all  other  types 
of  infectious  disease  mentioned,  an  early  diagnosis  and 
prompt  application  of  hyperemia,  based  on  such  timely, 
correct  interpretation  of  the  existing  symptoms,  can  pre- 
vent months  of  serious  illness  as  well  as  serious  surgical 
intervention. 

In  severe  cases  primary  opening  of  the  bone  cavity, 
followed  by  strict  hyperemic  treatment,  is  undoubtedly 
the  surest  road  to  recovery.  Nevertheless,  it  should  be 
mentioned  that  a  number  of  authors  have  accomplished 
the  same  result,  without  primary  opening  of  the  bone 
cavity,  by  means  of  hyperemia  alone. 

Advanced  cases  would  better  be  subjected  to  operation 
in  accordance  with  accepted  principles,  plus  artificial 
hyperemia. 

In  young  children,  thorough  incision  of  the  abscess  often 
suffices.  Drainage  of  the  central  cavity  and  chiseling  away 
of  the  covering  part  of  the  bone  are  not  imperative. 

Hyperemia  at  first  causes  voluminous  secretion,  after 
the  cessation  of  which,  in  the  absence  of  bone  necrosis,  the 
wound  may  close  without  the  formation  of  a  seques- 
trum. 

In  the  chapter  on  phlegmons  of  the  hand  it  was  empha- 


120  bier's  hyperemic  treatment. 

sized  that  the  main  object  of  the  hyperemic  treatment 
is  the  preservation  of  the  endangered  tendon.  The  same 
preservation  of  tissues  is  attempted  in  acute  osteomyehtis. 
Tamponade  is  aboUshed  in  order  to  avoid,  if  possible, 
the  formation  of  large  sequestra;  for  the  piece  of  gauze  or 
drainage  tube  that,  according  to  former  practice,  was  used 
to  cover  the  tendon  in  the  case  of  a  phlegmon  really  favors 
its  necrosis,  as  Bier  has  shown.  In  view  of  this  his  finding, 
drainage  is  abolished  also  in  these  acute  inflammations, 
in  order  to  prevent  the  drying  out  of  the  bone.  The  latter 
is  to  remain  covered  with  soft  parts  as  far  as  this  can  be 
done  in  a  given  case. 

.With  this  end  in  view,  the  operation  in  a  case  of  acute 
osteomyelitis  is  carried  out  as  follows:  The  abscess  is 
incised  and  irrigated  or  the  bone  opened.  Then  the  skin 
edges  are  brought  together  again  by  means  of  retention 
sutures,  IJ  to  2  inches  (4  to  5  cm.)  apart,  which  are  but 
loosely  tied.  Sufficient  space  must  remain  between  the 
sutures  to  permit  of  free  exit  of  the  secretion. 

This  treatment  tends  to  retard  the  spread  of  the  necro- 
sis of  the  bone,  as  has  been  proven  by  subsequent  seques- 
trotomy. 

In  cases  in  which  necrosis  of  the  bone  could  not  be 
avoided,  it  will  be  seen  that  hyperemic  treatment  favors 
the  rapid  formation  of  the  bone  cavity  encasing  the  se- 
questrum, and  also  facilitates  the  loosening  of  the  latter. 

It  should  be  borne  in  mind  that  hyperemic  treatment 
of  acute  osteomyelitis  is  still  in  its  infancy.  Further 
experience  is  sorely  needed.  So  far,  its  results  have  been 
but  moderately  satisfactory. 

No  surgeon  who  does  not  thoroughly  master  the  technique 


RECURRENT    OSTEOMYELITIS.       ERYSIPELAS.  121 

of  hyperemic  treatment  should  venture  to  try  it  in  these 
usually  grave  infections. 

The  possible  advent  of  metastatic  abscesses,  especially 
in  joints,  must  be  borne  in  mind  and  careful  examination 
made  accordingly. 

That  patients  stricken  with  acute  osteomyelitis  are 
hospital  cases  need  hardly  be  stated. 

Recurrent  Osteomyelitis. 
In  cases  of  recurrent  osteomyelitis,  viz.,  sinus  formation  Recurrent 
along  the  line  of  the  scar  after  operations  for  acute  osteo- 
myelitis or  its  sequela  (sequestrotomy ) ,  hyperemic  treat- 
ment by  means  of  the  elastic  bandage  plus  the  suction 
cups,  will  often  be  found  extremely  useful. 

Erysipelas. 

A  few  words  must  be  devoted  to  the  effect  of  artificial  Erysipelas, 
hyperemia  in  erysipelas. 

Although  further  observations  are  needed,  to  fully 
estimate  its  true  value,  this  much  can  be  definitely  stated 
even  now,  that  in  erysipelas  of  the  head  and  face  the 
application  of  obstructive  hyperemia  by  means  of  the 
elastic  neck-band  shortens  the  duration  of  the  disease, 
and  improves  the  patient's  general  condition,  not  only  in 
the  way  of  a  prompt  reduction  of  the  temperature,  but  also 
in  producing  early  and  pronounced  desquamation. 

Hyperemia  should  be  continued  for  a  few  days  even 
after  the  temperature  has  returned  to  normal. 

It  seems  justifiable  to  assume  that  the  good  results 
that  have  been  obtained  with  the  well-known  method  of 
applying  rather  tightly  circular  strips  of  adhesive  plaster 
near  the  border-line  of  the  erysipelas  within  healthy  skin, 
have  been  due  to  the  hyperemia  thus  induced. 


122  bier's  hyperemic  treatment. 

The  erratic  course  of  so  many  cases  of  erysipelas,  of 
course,  renders  attempts  at  fighting  its  progress  often 
illusory,  no  matter  what  method  of  treatment  be  employed. 


Obstructive  Hyperemia  as  a  Prophylactic. 

Obstructive  Hy-      The  recognition  that  Bier's  hyperemic  treatment  can 

peremia  as  a 

Prophylactic,      successfully  overcome  an  acute  infection,  and  that  the 

earlier  it  is  applied,  the  more  striking  is  its  effect,  evolved 
the  idea  of  the  possible  prophylactic  value  of  this  powerful 
agent  in  preventing  inflammation  and  suppuration  in 
cases  of  soiled  wounds,  or  at  least  having  the  inflammation 
take  as  mild  a  course  as  possible. 
Soiled  Wounds.  -Under  the  old  regime,  if  a  patient  came  under  our  care 
who  had  just  sustained  a  division  of  tendons  and  muscles 
with  visible  soiling  of  the  wound,  we  would  abstain  from 
performing  immediate  tenorrhaphy.  We  would  clean  and 
dress  the  wound  and  suture  the  tendons  when  the  danger 
of  inflammation  had  subsided.  The  increased  difficulty 
and  doubtful  result  of  such  secondary  suturing  are  suffi- 
ciently known. 

According  to  Bier,  if  the  contamination  of  the  wound  is 
not  too  severe  and  the  tissues  are  not  too  seriously  mangled 
and  torn,  such  wounds  are  gently  irrigated  with  physio- 
logic salt  solution,  avoiding  rough  handling  and  all  scrub- 
bing, and  tendons  and  muscles  are  united  with  chromicized 
gut;  the  skin  is  closed  with  sutures  of  silk  or  fine  silver 
wire,  placed  sufficiently  far  apart  to  insure  free  exit  of 
the  wound  secretion.  No  drainage  of  any  kind  is  employed. 
First,  a  slightly  compressing  dressing  is  applied,  to  guard 
against  hemorrhage.  About  three  hours  later  this  is 
replaced  by  a  loose  one  and  prophylactic  hyperemic  treat- 


OBSTRUCTIVE    HYPEREIMIA    AS    A    PROPHYLACTIC. 


123 


merit  is  started,  just  as  if  we  had  to  deal  with  a  true  infec- 
tion. 

As  has  been  often  said  before,  the  elastic  bandage 
remains  in  place  for  twenty  to  twenty-two  hours  each  day. 
The  secretion,  which  is  usually  abundant,  is  at  first  sero- 
sanguinolent  in  character  and  may  later  become  purulent. 
So  long  as  suppuration,  redness,  fever,  and  pains  continue 


Fig.  74. 


and  the  edema  is  marked,  the  bandage  must  be  strictly 
applied  for  the  full  length  of  time.  After  the  symptoms 
subside  the  time  is  gradually  reduced.  The  treatment 
must  never  be  abruptly  interrupted. 

Under  this  regime  one  often  sees  divided  tissues  unite 
without    complications.     Of    course,    the    resulting    scar 


12-4  bier's  hyperemic  treatment. 

does  not  correspond  in  appearance  to  that  following  aseptic 
healing  of  a  wound.*     Still,  it  is  linear. 

Case. — (See  Fig.  74.)  Man,  twenty-nine  years  old, 
sustained  two  deep  cuts  in  volar  aspect  of  forearm  by 
falling  on  brolven  glass;  wounds  are  soiled;  the  longer  one 
extends  down  to  the  ulna,  completely  dividing  the  various 
muscular  layers  as  well  as  the  ulnar  artery  and  vein. 
After  careful  cleansing  and  hemostasis,  layer  sutures, 
dressing.  Soon  rise  of  temperature.  Under  the  immediate 
application  of  the  elastic  bandage  for  twenty  hours  per 
day,  a  pronounced  obstructive  edema  appears  and  the 
fever  drops,  reaching  normal  on  the  sixth  day.  Hyperemic 
treatment  then  reduced  to  twelve  hours  per  day.  Wound 
entirely  healed  after  four  weeks,  in  spite  of  sero-purulent 
secretions  from  between  the  stitches  which  had  not  been 
removed. 

The  advantages  of  this  procedure  are  evident.  It  is 
necessary,  however,  to  again  call  attention  to  the  necessity 
of  individualizing  in  these  cases.  It  is  not  to  be  expected 
that  hyperemic  treatment  will  furnish  a  good  result  in 
every  case,  no  matter  how  badly  soiled.  It  cannot  do  this. 
It  is  not  a  panacea. 

If  the  wound  is  not  too  extensively  soiled,  this  prophyl- 
actic treatment  may  well  be  tried.  But  the  surgeon  has 
to  be  on  his  guard,  and  promptly  open  the  wound  should 
progressive  suppuration  set  in.  The  pus  must  have  an 
exit;  retention  cannot  be  tolerated,  possible  hidden  abscesses 
have  to  be  searched  for. 

*  In  order  to  avoid  ugly  scar-formation  and  to  produce  linear 
cicatrices,  it  has  been  proposed  to  paint  the  sutured  aseptic  wound 
with  tincture  of  iodin  at  the  completion  of  the  operation.  This,  of 
course,  produces  a  local  artificial  hyperemia  by  chemical  means. 
(See  Centralbl.  f.  Chirurgie,  July.  1908.) 


OBSTRUCTIVE    HYPEREMIA    AS    A    PROPHYLACTIC.       125 

This  prophj'lactic  hyperemic  treatment  seems  destined 
to  restrict  somewhat  the  free  incisions  and  operative 
after-treatment  of  infected  foci.  No  doubt  good  results 
were  obtained  with  the  latter  method,  as  far  as  healing 
was  concerned,  but  the  preservation  of  function  was  often 
somewhat  neglected. 

The  most  striking  results  of  Bier's  treatment  have  been 
obtained  in  this  class  of  cases.  Such  patients  are,  there- 
fore, suitable  material  for  the  beginner.  Later  he  may 
undertake  the  treatment  of  the  more  serious  affections, 
always  exercising  the  utmost  care  and  watchfulness  lest 
he  miss  the  proper  moment  for  the  various  steps  that  may 
become  necessary  in  the  course  of  the  treatment. 

The  compound  injuries  to  the  fingers  and  the  severe  Compoimd    In- 
crushings  of  the  hand  so  frequently  observed  in  industrial  gers  and  Hands, 
towns  are  greatly  benefited  by  prophylactic  obstructive 
hyperemia. 

Under  our  former  mode  of  treatment  the  necessary 
examination  as  to  the  extent  of  the  injury  was  very  pain- 
ful, often  harmful;  the  serious  swelling  of  the  parts  made 
a  strict  diagnosis  as  to  division  of  tendons  and  opening 
of  joints  rather  difficult;  it  was  impossible  to  determine 
whether  or  not  the  irregular  shreds  of  the  lacerated  skin  and 
how  much  of  the  crushed  and  broken  bones  would  live.  The 
rc-ray  alone  could  show  the  extent  of  bone  destruction.  Hence 
conservative  treatment  could  only  rarely  be  carried  out. 

With  the  prompt  application  of  Bier's  treatment,  on  the 
other  hand,  copious  secretion  from  the  wound  is  promptly 
started,  the  contaminating  particles  are  thereby  washed 
away,  and,  usually  sooner  than  expected,  healing  takes 
place.  The  reduced  sensitiveness  permits  of  early  motions 
which  prevent  stiffening. 


126 


BIER  S   HYPEREMIC  TREATMENT. 


Injuries  Sus- 
tained by 
Physicians  in 
the'^Course  of 
Operations  or 
Autopsies. 


The  possibility  of  thus  saving,  for  instance,  a  hand  or 
even  part  of  a  hand  to  a  man  who  Uves  by  manual  labor 
certainly  ought  to  be  sufficient  incentive  to  the  surgeon 
to  most  carefully  study  a  method  that  holds  out  such 
promise. 

Under  Bier's  treatment  operations  on  these  mangled 
limbs  rarely  become  necessary;  they  are  resorted  to  only 
in  cases  of  exceptionally  severe  crushing.  Secondary 
operations  for  the  correction  of  the  stump  can  be 
reduced  to  a  minimum. 

If  disarticulations  of  fingers,  etc.,  must  nevertheless  be 
done,  the  hyperemic  treatment  following  the  operation 
promptly,  will  overcome  the  necessity  of  drainage. 

In  this  connection  it  may  be  well  to  call  attention  to 
the  value  of  the  treatment  in  the  finger  injuries  sometimes 
received  by  physicians  during  septic  operations  or  post- 
mortem examinations.  Prompt  prophylactic  hyperemic 
treatment  wiU  prevent  many  a  serious  lymphangitis  or 
lymphadenitis.  It  is  best,  immediately  after  the  wound 
has  been  inflicted,  no  matter  how  small  it  may  be,  to  stop 
in  the  operation,  if  at  all  possible,  long  enough  to  squeeze 
the  finger  until  blood  appears,  cover  it  with  a  small  piece 
of  wet  sterile  gauze,  draw  a  finger-cot  over  the  same  and 
slip  a  small  rubber  band  over  the  base  of  the  finger,  as  shown 
in  Fig.  63.  Then,  after  putting  on  the  glove  again,  the 
operation  can  be  proceeded  with.*  Later  a  second  rub- 
ber band  may  be  applied  in  order  to  increase  the  passive 
hyperemia.  Of  course,  the  constriction  must  not  be 
painful.     It  will  be  advisable  for  the  physician  to  always 


*  If  gloves  and  finger-cots  are  not  or  can  not  be  worn,  the  rubber 
band  should  at  least  be  slipped  over. 


OBSTRUCTIVE    HYPEREMIA    AS    A    rROPHYLACTIC.       127 

carry  in  his  pocket  a  small  box  containing  rubber  cots  and 
bands.  They  should  also  be  kept  ready  (sterilized)  for 
emergencies  at  our  hospitals. 

In  case  of  the  infliction  of  a  deeper  wound  on  the  fingers, 
as  also  in  the  event  of  injury  to  the  first  phalanx,  meta- 
carpal or  carpal  region,  obstructive  hyperemia  with  the 
bandage  around  the  arm  should  be  employed,  as  soon  as 
the  operation  or  dissection  has  been  finished. 

The  same  prophylactic  hyperemic  treatment  is  advisable, 
perhaps  indicated,  in  poisoned  wounds  of  different  charac- 
ter, e.  g.,  those  inflicted  by  mad  dogs  and  poisonous  snakes. 

It  has  been  suggested  to  use  the  suction  cups  as  soon  as  Rabies, 
ever  possible  after  the  infliction  of  the  wound.     If  the 
extremities  are  involved,  obstructive  hyperemia  by  means 
of  the  bandage  may  be  added.     Of  course,  this  does  not 
exclude  additional  treatment  at  a  Pasteur  Institute. 

Snake-bites  have  been  effectively  sucked  out  by  mouth  Snake-bites. 
from  time  immemorial.  This  practice  retains  its  value  up 
to  the  present  day.  Tight  constriction  above  the  wound 
has  also  been  extensively  practised,  the  idea  being  that 
this  will  prevent  the  poison  from  promptly  entering  the 
circulation,  while  the  living  tissues  meanwhile  reduce  the 
virulence  of  the  poison. 

Obstructive  hyperemia  works  similarly.  The  edema, 
soon  developing  with  the  continued  use  of  the  elastic 
bandage,  materially  dilutes  the  poison,  thus  rendering  it 
less  deadly.  An  assortment  of  suction  cups  and  elastic 
bandages  rightly  belongs  to  the  outfit  of  people  living  in 
territories  infested  by  these  venomous  reptiles. 

In  the  direction  of  prophylaxis  probably  lies  the  widest 
field  of  usefulness  of  artificial  hyperemia.     It  is  but  natural 


128 


BIER'S    HYPEREMIC   TREATMENT. 


To  Avoid 
Vomiting  after 
Superficial 
Ether 
Anesthesia. 


To  Prevent 
the  Annoying 
After-effects 
of  Spinal 
Anesthesia. 


Hyperemesis 
Gravidarum. 


that  it  will  here  be  gradually  more  extensively  made  use 
of  in  various  directions. 

Obstructive  hyperemia  has  lately  been  recommended 
as  a  means  of  preventing  vomiting  and  dizziness  following 
the  inductive  stage  of  general  anesthesia  by  means  of  sul- 
phuric ether.  The  elastic  neck  bandage  applied  rather 
tightly  immediately  after  the  completion  of  the  operation, 
and  worn  for  one-half  to  one  hour,  has  prevented  the 
above-mentioned  symptoms.  Of  sixty-two  patients  thus 
treated  at  the  dispensary  clinic,  none  had  any  annoying 
after-effects,  except  one,  and  this  patient  had  been  under 
the  influence  of  the  anesthetic  for  twenty  minutes. 

Explanation  of  the  phenomenon:  The  artificial  hyper- 
emia reduces  the  effect  of  the  poison  upon  the  brain. 

Bier  has  used  the  neck-band  to  overcome  the  dis- 
agreeable effect  of  spinal  anesthesia  on  the  central  nervous 
system.  His  explanation  is  that  the  artificially  increased 
intracranial  pressure  prevents  the  cerebrospinal  fluid, 
with  the  injected  drug,  from  remaining  in  extended  con- 
tact with  the  upper  portions  of  the  cord  and  brain  and 
presses  it  downward.  This  reasoning  has  been  confirmed 
by  the  experiments  of  other  investigators. 

Among  all  the  conditions  producing  vomiting  through 
irritation  of  the  brain,  that  causing  the  continued  vomiting 
in  pregnant  women  should  be  first  studied  as  to  its  possible 
amenability  to  obstructive  hyperemia. 


Compound 
Fractures. 


APPENDIX. 
COMPOUND  FRACTURES. 

The  expert  may  use  Bier's  hyperemia  to  advantage 
also  in  cases  of  compound  fracture. 


COMPOUND    FRACTURES.  129 

The  question  that  usually  arises  in  these  cases  is:  Shall 
we  temporize,  or  shall  we  at  once  proceed  to  revise  the 
fracture;  that  is  to  say,  lay  open  the  fragments,  clean, 
shape,  unite,  etc.,  and  then  treat  the  wound  according  to 
indications?  As  a  rule,  the  former  course  is  decided  upon  for 
the  less  severe  cases,  the  latter  for  the  more  serious  cases. 

Obstructive  hyperemia,  begun  as  soon  as  the  wounds 
have  been  properly  attended  to  and  protected  by  a  loosely 
applied  aseptic  dressing,  with  the  limb  placed  on  splints, 
seems  destined  to  shift  the  borderline  between  these  two 
modes  of  treatment  in  favor  of  the  conservative  plan. 

To  be  successful,  the  treatment  has  to  be  applied  faith- 
fully for  twenty  hours  each  day;  regular  and  careful 
examination  has  to  be  made  in  order  to  detect  any  possible 
retention  of  serum,  or  pus  formation.  As  the  pain  decreases, 
the  position  of  the  fragments  is  gradually  corrected,  always 
under  continuance  of  the  loose  aseptic  dressing.  As 
soon  as  the  time  for  a  threatening  infecti'on  has  passed,  a 
plaster-of-Paris  splint  with  one  or  more  cut-outs  is  applied 
and  the  hyperemic  treatment  discontinued. 

One  of  the  most  dreaded  of  compound  fractures  is  that  S^^*^*"J^o,°^  „ 

^     .  Base  of  Skull, 

of  the  base  of  the  skull.     Intracranial  hemorrhage  and 

meningitis  here  endanger  the  patient's  life. 

Of  all  the  methods  of  treatment  known  and  used  nowa- 
days, prophylactic  hyperemia  of  the  head  with  the  elastic 
band  around  the  neck,  started  immediately  after  the 
injury,  seems  to  promise  the  best  results  in  these  cases, 
as  it  is  most  apt  to  prevent  meningitis.  Nor  is  it  to  be 
feared,  in  view  of  the  absorbing  qualities  of  hyperemia, 
that  it  will  produce  or  increase  intracranial  bleeding. 

Case. — Boy,    twelve,    falls    down   high    stairs,    striking 
9 


130  bier's  hyperemic  treatment. 

head-first  iii)on  stone  floor;  unconscious;  severe  hemor- 
rhage from  mouth  and  nose.  Six  hours  later  admitted 
to  hospital;  still  dazed;  streaks  of  coagulated  blood  adhe- 
rent to  phar3-nx.  Immediate  head  hyperemia.  Con- 
sciousness returns  rather  quickly;  no  fever;  no  meningeal 
complications.  Subperiosteal  blood  effusions  become  ab- 
sorbed in  comparatively  short  time.  Discharged  after 
two  weeks. 

Case. — Boy,  thirteen;  run  into,  and  thrown  a  distance 
of  several  feet  by  automobile.  Brought  to  hospital  by 
ambulance.  Unconscious.  Severe  hemorrhage  from  right 
ear;  slight  facial  palsy  on  right  side.  Fracture  of  right 
thigh.  Rupture  of  right  drum  membrane  clearly  visible; 
bloody  oozing.  Immediate  head  hyperemia  by  means 
oF  the  elastic  neck-band,  eleven  hours  out  of  every  twelve. 
Iodoform  guaze  tamponade  of  external  meatus  of  right 
ear;  splint  to  thigh.  Consciousness  soon  begins  to  re- 
turn, though  not  fully;  patient  remains  in  sort  of  slight 
stupor  for  several  days.  On  third  day  after  beginning 
of  treatment,  discharge  from  ear  turns  serous.  Slight 
fever,  which  gradually  drops  to  normal.  No  intracranial 
complications.  Head  hyperemia  slowly  reduced.  Dis- 
charged cured. 

This  probably  salul^rious  prophylactic  effect  from  the 
use  of  the  elastic  neck-band  in  fractures  of  the  skull  and 
base  of  the  skull  is  to  be  expected,  it  seems,  rather  in 
cases  associated  with  a  rupture  of  the  drum  membrane 
or  the  nasopharyngeal  mucosa,  viz.,  in  cases  in  which 
there  is  an  external  exit  for  drainage. 

If  no  such  external  rupture  is  evident,  it  is  suggested 
that  the  surgeon  promptly  trephine  the  skull  at  a  suitable 
place,  introduce  one  or  two  split  drainage-tubes  in  the 
epidural  space,  and  then  immediately  start  hyperemic 
treatment.     It   goes   without   saying   that   further   intra- 


TUBERCULOSIS.  131 

cranial  operative  work  should  be  promptly  carried  out,  if 
needed. 

The  rather  rapid  awakening  from  stupor  after  injury 
to  the  head  under  the  influence  of  head  hj'peremia  is  very 
interesting  and  deserves  further  study.  It  was  rather 
conspicuous  in  the  following: 

Case. — Man,  laborer,  forty  years  old,  hit  by  a  fellow- 
worker  on  right  frontal  bone  with  hammer.  Flesh  wound, 
no  fracture,  semi-unconsciousness.  Neck-band.  Wide 
awake  after  two  hours. 

It  remains  to  be  seen,  what  benefit  the  treatment  brings 
in  cases  of  concussion  of  the  brain. 

Comparative  statistics  of  cases,  treated  by  this  and  the 
other  methods,  would  be  best  adapted  to  definitely  estab- 
lish the  merits  or  demerits  of  this  proposed  prophylactic 
treatment. 

It  need  hardly  be  added  that  compound  fractures  are 
hospital  cases,  and  physicians  will  do  well  to  urge  their 
patients  to  enter  a  hospital  or  clinic,  where  they  have  the 
advantages  of  strict  asepsis  and  continuous  observation 
by  competent  physicians  and  nurses. 

CHRONIC  INFECTIONS. 
Tuberculosis. 

I.  Tuberculosis  of  Joints. — This  section  is  of  especial 
interest,  inasmuch  as  it  was  the  treatment  of  this  trouble 
that  gave  birth  to  the  use  of  hyperemic  treatment.  The 
principal  studies  in  regard  to  the  peculiarities  and  effect 
of  this  therapeutic  agent  have  been  made  on  patients 
afflicted  with  tuberculous  joint-disease. 

After  a  most  interesting  development,  the  treatment 
of  tuberculosis  of  the  joints  by  means  of  artificial  hyper- 


132  bier's  hyperemic  treatment. 

emia  has  been  brought  to  such  a  stage  of  perfection  that  it 
may  now  be  looked  upon  as  one  of  our  most  important 
aids  in  the  conquest  of  this  class  of  diseases. 

It  is  to  be  emphasized  right  here  that  artificial  hyperemia 
requires  longer  to  effect  a  cure  than  operative  treatment, 
a  drawback  which  it  has  in  common  with  all  other  conserva- 
tive methods.  He  who  desires  to  be  cured  quickly  would 
probably  better  submit  to  resection  or  amputation. 

The  laborer  dependent  upon  his  wages  for  a  living  for 
himself  and  family  will  probably  be  earlier  able  after  an 
operation  to  resume  his  work  than  if  treated  by  hyperemia. 
And  it  must  be  admitted  that  our  present  refined  methods 
of  resection,  particularly  if  Mosetig's  iodoform  fillings 
or  E.  Beck's  bismuth  paste  be  employed  for  the  resulting 
cavity,  insure  a  quick  and  usually  good  functional  result, 
at  least  in  the  wrist-,  elbow-,  and  ankle-joint.  Yet  this 
mutilating  treatment  could  not  be  the  final  aim  of  scientific 
surgery;  and  we  now  have  something  better  in  Bier's 
hyperemic  treatment,  which  aims  to  restore  perfect  func- 
tion without  sacrificing  any  part  of  the  limb  or  joint  itself. 

It  is  true  a  great  deal  of  patience  and  perseverance 
are  required  to  attain  this  end,  as  it  takes  many  months 
(about  twelve  to  fifteen)  of  treatment  and  careful  medical 
supervision;  but  the  final  result  in  most  cases  amply 
repays  both  patient  and  surgeon. 

It  is  difficult  to  give  a  correct  explanation  for  the  curative 
effect  of  artificial  hyperemia  in  tuberculous  cases.  The 
best  seems  to  be,  that  gradually  connective  (scar-)  tissue 
takes  the  place  of  the  tuberculous,  and  that  connective 
tissue  does  not  represent  a  soil  in  which  the  tubercle 
bacillus  can  flourish.  It  dies,  and  therewith  its  pathologic 
sequelse  come  to  an  end. 


TUBERCULOSIS.  133 

In  the  treatment  of  surgical  tuberculosis  obstructive  hyper-  Form  of  Hy- 

7       7         7-77  -7  •  7    pereiiiia. 

emia  only,  by  elastic  bandage  or  suction  glasses,  is  used; 

never  hot  air. 

The  elastic  bandage  is  used  far  more  extensively  than 
suction  glasses.  It  can  be  nicely  applied  in  tuberculous 
inflammations  in  the  greater  number  of  joints  of  the  ex- 
tremities, including  the  shoulder. 

It  is  to  be  regretted  that,  so  far,  the  hip-joint  cannot 
be  subjected  to  this  treatment,  the  impossibility  being  given 
by  the  necessity  of  employing  venous  hyperemia  only.* 

As  a  rule,  a  tuberculous  joint  is  treated  with  obstructive  Duration  of  Ob- 
hyperemia  twice  a  day  for  one  hour,  although  this  rule  pJr^mia!     ^' 
may  have  to  be  modified  in  some  instances.     If  observa- 
tion shows  that  a  somewhat  longer  duration  of  treatment 
gives  a  better  result,  also  as  regards  relieving  the  pain, 
the  time  may  be  extended  to  twice  two  hours  per  day. 

In  severe  and  rapidly  progressive  cases  a  still  longer 
duration  of  obstructive  hyperemia,  twice  per  day,  may 
become  necessary. 

In  cases  of  hot  abscess-formation  with  fever,  due  to 
mixed  infection  of  the  sinuses  present,  the  treatment  will 
have  to  be  extended  to  twice  eleven  hours  per  day.  After 
the  acute  stage  has  passed,  the  shorter  periods  of  treatment, 
with  nine  to  eleven  hours  intermission,  are  resumed. f 

*  See  page  36,  foot-note. 

t  Originally  Bier  advised  obstructive  hyperemia  for  eleven  hours  of 
each  twelve  for  tuberculous  cases.  It  was  seen,  however,  in  course  of 
time,  that  a  persistent  chronic  edema  appeared,  which  often  gave  rise 
to  the  development  of  erysipelas  in  fistulous  (open)  cases.  The  cause 
for  the  setting  in  of  such  unwelcome  complication  evidently  is  the 
edema-fluid,  the  bactericidal  power  of  which  had  been  used  up. 

Since  employing  the  obstructive  hyperemia  twice  per  day  for  one  to 
two  hours  only,  a  complicating  erysipelas  has  not  been  observed  by 
Bier  again. 


134  bier's  hypere:mic  treatment. 

This  shows  that  here,  as  elsewhere,  we  have  to  individ- 
uahze.  At  times  a  period  of  continuous  improvement 
IS  followed  by  one  of  comparatively  little  improvement 
in  spite  of  most  painstaking  application.  In  such  an 
event  it  may  be  advisable  to  discontinue  the  treatment 
for  a  while,  say  from  six  to  eight  days,  after  which  the 
resumed  treatment  will  often  yield  more  satisfactory 
results. 

To  understand  this,  it  must  be  borne  in  mind  that 
obstructive  hyperemia  acts  like  a  powerful  drug,  the  dosage 
of  which  must  be  adapted  to  the  individual  case. 

But,  as  has  been  stated  above,  the  general  rule  in  un- 
complicated cases  of  tuberculous  joint  disease  is,  to  apply 
the  elastic  bandage  twice,  one  hour  per  day.  During 
this  time  the  induction  of  a  "strong  hyperemia"  should 
be  the  aim,  that  is  to  say,  that  part  of  the  extremity 
which  is  distal  to  the  bandage  should  turn  a  bluish-red, 
without,  however,  becoming  painful. 

The  possibility  of  a  good  result  from  such  brief  applica- 
tions of  the  elastic  bandage  twice  per  day,  is  certainly  a 
great  boon  to  patients  belonging  to  the  working  classes. 

They  can  apply  the  treatment  in  the  morning  before 
going  to  work  and  again  after  their  return  at  night,  mean- 
while carrying  the  arm  in  a  sling,  making  themselves 
useful  with  one  arm,  or  performing  some  light  work  with 
both,  as  soon  as  some  improvement  has  set  in.  If  the 
lower  extremity  be  involved,  they  can  apply  for  work 
that  can  be  done  mostly  in  a  sitting  posture.  In  this  way 
they  can  at  least  earn  some  money  and  will  not  be  an 
absolute  burden  to  the  community  or  their  families  during 
the  long  course  of  the  treatment.     Of  course,  it  would  be 


TUBERCULOSIS.  135 

far  better  if  such  patients  did  not  have  to  Avork,  but  could 
enjoy  outdoor  hfe. 

The  bandage  must  always  cover  a  'perfectly  healthy  part  Technique. 
of  the  extremity,  not  too  close  to  the  diseased  joint.     In  tuber- 
culous affections  of  the  elbow  and  joints  below  the  same 
the  bandage  is  best  applied  around  the  arm.     (Fig.  75.) 

For  the  treatment  of  the  shoulder-joint  an  elastic  tube 
is  employed  instead  of  a  bandage;  this  is  kept  in  place  by 
means  of  strips  of  muslin  or  gauze,  fastened  in  a  simple 
way.  (See  Fig.  5.)  Special  care  must  be  exercised  in 
the  treatment  of  these  cases,  as  the  elastic  tube  necessarily 
always  encircles  the  same  spot,  and,  hence,  may  give  rise 
to  pressure  necrosis  of  the  skin. 

In  cases  of  tuberculosis  of  the  knee,  tibiotarsal  articula- 
tion, and  the  small  joints  of  the  foot  the  bandage  is  worn 
around  the  thigh. 

In  stout  patients  the  elastic  bandage  has  to  be  wider — 
3  to  3|  inches  (8  to  9  cm.) — and  is  best  made  to  cover 
a  thin  gauze  compress  or  a  layer  of  cotton,  as  otherwise, 
owing  to  the  tapering  form  of  the  thigh,  it  would  be  likely 
to  be  pulled  into  a  narrow  band  and  cause  pain. 

In  order  to  increase  the  effect  of  the  bandage,  a  hot  bath 
of  the  parts  of,  say,  ten  minutes'  duration  may  be  helpfuL 

After  the  removal  of  the  bandage  the  portion  of  the 
extremity  that  w^as  subjected  to  the  elastic  compression 
is  thoroughly  massaged  in  order  to  guard  against  pressure 
atrophy  of  the  muscles.  For  the  same  reason  the  bandage 
is  never  reapplied  in  exactly  the  same  spot,  but  1  to  1| 
inches  (3  to  4  cm.)  further  up  or  down,  thus  wandering 
between  the  joint  above  and  a  place  of  safe  distance  from 
the  focus  of  the  disease. 


136 


BIERS    HYPEREMIC   TREATMENT. 


As  a  rule,  all  dressings  (in  the  case  of  open  tuberculosis) 
are  removed  while  the  bandage  is  in  place.  The  sinuses 
are  loosely  covered  with  aseptic  gauze,  and  the  limb  is 
wrapped  in  a  towel  so  as  to  retain  its  warmth. 

In  addition  to  the  elastic  bandage,  suction  glasses  are 
applied  in  these  cases  of  open  bone  tuberculosis  for  forty- 


Fig.  75. — This  illustration  shows  the  manner  of  application  of  the  elastic 
bandage  in  a  case  of  fistulous  tuberculosis  of  the  elbow-joint. 

five  minutes  per  day,  with  the  usual  interruptions;  that  is 
six  to  five  minutes  on  and  two  to  three  minutes  off,  but 
best  while  the  bandage  is  not  in  place.  (Fig.  76.)  Care 
must  be  taken  to  select  the  proper  size  of  glass. 

By   means   of   this   local   suction-hyperemia   whatever 


TUBERCULOSIS. 


137 


purulent  secretions  and  necrotic  shreds  may  be  present  are 
aspirated. 

The  joints  are  not  put  in  fixation  splints  during  treat- 
ment. If  but  a  minimum  degree  of  mobility  is  left,  the 
patient  is  urged  to  gently  but  frequenth'  exercise  the  joint, 
in  order  to  preserve  and  increase  such  mobility. 


Fig.  76. — Shows  the  patient  with  tuberculosis  of  the  elbow  represented 
by  Fig.  75  with  the  suction  glass  in  operation. 

Only  extremely  painful  joints  are  immobilized,  but  the 

splint  is  left  off  just  as  soon  as  the  sensitiveness  subsides. 

If  no  pain  be  experienced,  the    patient  may  use    the  Permissibility 

of  Using  the 

affected  limb  to  some  extent.     He  may  dress  himself  in  Diseased  Joints, 
the  presence  of  a  diseased  joint  of  the  upper  extremity. 
He  may  be  out  of  bed  part  of  the  time  each  day,  with  a 


138  bier's  hyperemic  treatment. 

tuberculous  knee-  or  foot-joint.  But  in  the  latter  case 
the  joint  must  be  carefully  protected  against  overweight. 
Pressure  of  the  two  diseased  articulating  surfaces  is  strictly 
to  be  avoided.  So  long  as  these  joints  are  in  an  inflamma- 
tory stage,  the  patient  has  to  wear  a  support  of  some  kind 
and  use  crutches  or  a  cane.  The  best  and  safest  way  to 
guard  against  unduly  burdening  the  joints  with  the  weight 
of  the  body,  is  to  apply  a  movable  splint  while  the  patient 
is  out  of  bed  (Figs.  77  and  78) ;  the  active  exercises  to  be 
undertaken  while  he  is  in  bed. 

In  order  to  avoid  misunderstanding  it  should  be  stated 
right  here,  that  neither  a  systematic  movement-therapy 
nor  brisement  force  is  ever  indicated.  Such  procedure 
would  surely  make  things  worse.  The  patient  must 
know  that  traumatism  of  any  kind  is  apt  to  again  light  up 
the  receding  trouble. 
Contractures.  In  the  cases  in  w^hich  the  local  trouble  has  reached  an 
advanced  stage,  or  contracture  of  the  joint  has  set  in, 
gradual  reposition  is  to  be  combined  with  hyperemic 
treatment.  This  has  reference  especially  to  the  knee, 
where  the  pathologic  posture  is  usually  obstinate  and  easily 
leads  to  subluxation.  An  adhesive-plaster  extension 
splint  is  promptly  applied  in  these  cases  and  obstructive 
hyperemia  begun  at  the  same  time.  The  splint  leaves 
the  knee  fully  exposed  and  remains  in  place  until  the 
extremity  is  straightened.  Then  it  is  dispensed  with  and 
brought  into  use  again  only  in  case  of  a  return  of  the  con- 
tracture.    (Fig.  79.) 

Case. — Patient,  sixteen,  sick  for  six  months;  left  knee 
very  painful,  contracted  at  right  angle;  no  abscess;  slight 
mobility    preserved;     muscles    markedly    atrophied.     No 


TUBERCULOSIS. 


139 


fever.  Obstructive  hyperemia  daily,  two  times  two  hours; 
extension  sphnt;  gentle  exercises  permitted.  Two  weeks 
later  much  less  sensitive;  mobility  improved;  swelling 
reduced;  knee  almost  straight.     (See  Fig.  79.) 


Fig.  78. 

Fig.  77. — Shows  a  plaster-of-paris  support,  easily  improvised  by  the 
surgeon.  A  snugly  fitting  splint  reaches  from  the  ankles  to  the  tuber 
ischii.  It  carries  at  its  lower  end  a  stirrup,  lifting  the  foot  above  ground. 
By  splitting  this  splint  open  in  front  and  behind,  it  is  made  movable. 
It  is  lined  with  felt  and  applied  to  the  extremity  by  means  of  a  few 
straps  fastened  by  buckles.  By  taking  its  support  on  the  pelvis,  the 
knee  will  not  bear  any  weight.  It  is  not  fixated.  A  cork  sole  under 
or  in  the  shoe  of  the  healthy  side  corrects  the  difference  in  length. 
The  apparatus  is  applied  as  soon  as  the  knee  has  become  straightened 
and  painless  under  the  hyperemia  treatment. 

Fig.  78. — Illustrates  the  same  idea  as  carried  out  by  the  instrument- 
maker.     The  machine  is  worked  from  a  plaster  cast. 


140 


BIER  S    HYPEREMIC   TREATMENT. 


Daily  examination  to  make  sure  that  no  cold  abscess 
be  forming.  After  further  three  weeks  knee-fungus 
harder;  flexion  to  right-angle  possible,  extension  splint 
removed;  still  in  bed.  Same  hyperemic  treatment  two 
times  two  hours  daily.  Two  months  after  admission,  out  of 
bed.  Has  bad  effect;  joint  effusion;  back  to  bed.  After 
another   six  weeks,   up  regularly  with   movable   plaster- 


Fig.  79.- — This  illustration  shows  the  combined  treatment  of 
a  contracted  tuberculous  knee-joint  by  obstructive  hyperemia, 
and  gradual  reposition  by  means  of  a  plaster  splint  with  pulleys 
and  weights.  The  elastic  bandage  remains  in  place  for  two 
hours,  twice  a  day,  the  splint  continuously.  Atrophy  of  the  ex- 
tremity and  fungous  swelling  of  the  knee  are  evident.  There  is 
no  tuberculous  hydrops.  Only  light  weights  are  used,  5  to  8  pounds  in 
adults,  2  to  3  pounds  in  children.  To  avoid  any  sudden  stretching,  a 
safety  roll  is  placed  in  the  popliteal  space,  which  is  gradually  reduced 
in  circumference. 


The  Course  of 
the  Disease  un- 
der Hyperemic 
Treatment. 


of -Paris  support  (see  Fig.  77),  which  is  always  taken  off 
on  lying  down.  Four  and  a  half  months  after  admission: 
knee  swelling  materially  reduced;  muscular  atrophy  less 
marked;  articular  contours  more  normal,  Hyperemic 
treatment  continued  as  before.  Eleven  months  later 
examination  shows  no  more  signs  of  tuberculous  inflam- 
mation. Can  actively  flex  joint  to  right  angle,  (See  Fig.  81.) 
Knee  configuration  almost  normal.     (See  Fig.  80.) 

Improvement  in  such  joints  usually  sets  in  in  the  course 
of  a  number  of  weeks.  Nights  disturbed  by  pain  give  way 
to  restful  sleep.  Swelling  and  pain  recede.  The  contours 
of  the  joint  become  more  defined  and  mobility  increases. 


TUBERCULOSIS. 


141 


The  latter  constitutes  one  of  the  principal  advantages 
of  Bier's  treatment.  Whereas  we  have  been  accustomed 
to  looking  upon  joint  stiffness  as  a  characteristic  result  of 
joint  tuberculosis,  we  have  learned  through  Bier's  treat- 


Fig.  80.  Fig.  81. 

Figs.  80  and  81. — Showing  cured  tuberculosis  of  the  left  knee. 

ment  that  this  phenomenon  has  often  been  due  to  our 
therapeutic  measures  rather  than  to  the  disease   itself. 

Case. — Man,  forty-five,  always  active  worker.  Tuber- 
culosis of  right  elbow;  typical  picture;  unable  to  carry 
weight  of  forearm  and  hand  without  supporting  latter; 
sleeps  poorly.     Prognosis  of  resection  unfavorable  as  to 


142 


BIER  S    HYPEREMIC    TREATMENT. 


functional  result,  Hyperemic  treatment  with  elastic 
bandage.  Two  weeks  later:  can  raise  arm  without  assist- 
ance of  other  hand;  sleeps  much  better.  Treatment 
faithfully  continued  for  nine  months  without  interruption. 
Then  has  useful  arm;  returns  to  work.     Brilliant  result. 

In  a  number  of  cases  a  cold  abscess  forms,  which,  of 
course,  must  be  evacuated. 

Wliile  an  open  tuberculous  process  represents  a  graver 
form  of  the  trouble,  it  has  often  been  noted  that  a  turn 


Fig.  82. — This  illustration  represents  a  little  girl  with  a  serious 
tuberculous  affection  of  the  metatarsus.  Hyperemia  is  produced  by  a 
suction  glass  of  large  size.  A  smaller  glass  covers  a  sinus  at  the  neck, 
being  the  result  of  a  tuberculous  glandular  trouble. 

for  the  better  sets  in  as  soon  as  this  breaking  down  occurs. 
The  system  seems  to  rid  itself  of  the  necrotic  tissue  by 
way  of  suppurative  softening,  resulting  in  a  cold  abscess. 
This  then  is  opened  by  means  of  a  small  incision,  the  pus 
is  allowed  to  escape,  and  the  sinus  is  placed  under  artificial 
suction  hyperemia.     (Fig.   82.)     In   favorable   cases   the 


TUBERCULOSIS. 


143 


secretions  soon  become  serous  under  this  regime,  gradually 
cease,  and  the  sinus  closes. 

Here,  again,  the  same  hnportant  rule  for  the  successful 


Fig.  83. — Showing  daily  scene  at  children's  ward,  German  Hospital, 
New  York.  The  little  girl  has  been  taught  to  use  the  .suction  pump 
herself.  She  works  it  as  long  as  the  slowly  increasing  vacuum  in  the 
glass  does  not  create  pain.  Some  of  her  little  playmates  look  on, 
praising  her  sincerely. 

carrying  out  of  obstructive  hyperemia  applies:    opening 
of  the  abscess  in  order  to  evacuate  the  pus. 


144  bier's  hyperemic  treatmext. 

Yet,  aspiration  plus  injection  of  sterilized  iodoform- 
glycerin-emulsion  (five  to  ten  per  cent.)  also  remains  a  recom- 
mendable  procedure,  in  conjunction  with  Bier's  hyperemic 
treatment,  when  dealing  with  the  ordinary  cold  abscess, 
principally  in  private  practice.  Such  combined  treatment 
is  advisable  in  cases  in  which  the  surgeon  has  not  the  time 
to  personally  attend  to  the  patient  for  about  one  hour 
daily  and  a  nurse  is  not  available,  or  if  lack  of  intelligence 
on  the  part  of  the  patient  or  his  relatives  makes  the  surgeon 
fear  that  his  instructions  will  not  be  properly  carried  out. 

It  is  recomimended  that  the  physician  who  employs 
Bier's  hyperemic  treatment  follow  it  up  in  a  scientific 
manner;  namely,  that  he  carefully  note,  at  the  time  of 
starting,  the  degree  of  mobility,  the  circumference,  sensi- 
tive spots,  the  beginning  of  softening,  etc.  In  fact,  it 
would  be  very  interesting  and  instructive  to  take  an 
x-ray  picture  at  that  time.  This  would  often  clearly  show 
tuberculous  foci  in  the  bones  which,  by  the  way,  would 
not  mean  a  contraindication  to  the  use  of  obstructive 
hyperemia.  Well-defined  tuberculous  sequestra  should, 
of  course,  be  removed  by  operation. 

It  is  sometimes  difficult  to  gain  the  confidence  of  young, 
timid  children.  What  intelligent  nurses  can  accomplish 
in  this  direction  is  nicely  illustrated  by  Fig.  83,  which  was 
taken  at  the  children's  ward. 

Case. — Girl,  two  years  and  nine  months;  sick  for  several 
months.  Open  tuberculosis  of  tarsus  and  metatarsus  of 
both  feet.  Multiple  sinus  formation.  x-Ray  had  shown 
bone  foci.  Child  much  frightened;  screams  as  soon  as 
bandage  above  knee  is  put  on  and  suction  cup  applied 
during  intermission.     (Suction  apparatus  improvised  by 


TUBERCULOSIS.  145 

putting  elastic  cuff  on  suction  glass  for  the  treatment  of 
mastitis,  see  Fig.  24.)  Nurses  keep  other  children  around 
and  let  little  patient  herself  produce  the  vacuum  with 
syringe,  of  course,  carefully  watching  the  degree.  Six 
months  in  hospital;  then  all  sinuses  closed;  walks  without 
pain.  Advised  to  continue  hyperemia  with  bandage 
during  night.     General  hygienic  regime  continued. 

Tuberculosis  of  the  Spine,  Ilio-sacral  Joint  and  Os  Tuberculosis  of 

Sacrum.— Tuberculosis  of  the  spine  can  also  be  treated  by  column  (Pott's 
artificial  hyperemia.  The  earlier  it  is  applied,  the  more  ^^?^^^^  °^  the 
promising  the  result.  Of  course,  only  suction  glasses  can 
be  made  use  of.  Experiments  and  experience  have  shown 
that  the  hyperemic  depth-effect  of  these  glasses  amounts 
to  several  inches.  We  can  thus  understand  how  the  diseased 
body  of  the  vertebrae  may  be  placed  under  artificial  hyper- 
emia in  this  manner. 

The  selection  of  the  proper  size  of  glass  is  of  greatest 
importance.  The  glass  should  be  large  and  cover  a  num- 
ber of  vertebrae  above  and  below  the  affected  region. 
According  to  location,  the  brim  of  the  glass  must  be 
straight  or  U-shaped.  In  cases  in  which  it  does  not 
readily  adhere  one  may  facilitate  air-tight  suction  by 
pushing  the  neighboring  skin  and  muscles  toward  the 
apparatus,  the  rim  of  which  should  always  be  anointed 
with  a  mixture  of  lanolin  and  vaselin,  equal  parts,  or  by 
snugly  covering  the  rim  with  a  strip  of  Billroth-battist.* 

In  these  cases  the  hyperemic  treatment  is,  naturally, 
but  a  part  of  the  regular  treatment,  but  it  is  a  very  essential 
part.  Its  use  forbids  an  immovable  plaster  jacket  in  the 
beginning;  if  such  be  deemed  necessary  later  on,  it  will 
have  to  have  a  large  window  cut  out. 

*  By  slipping  a  stiff  rubber  cuff  on  to  glass  cups  of  round  or  oval 
shape,  even  spines,  the  adjacent  muscles  of  which  are  atrophied  and  do 
not  give  a  proper  hold  for  the  ordinary  cup,  can  be  effectively  subjected 
to  suction  treatment. 
10 


146  bier's  hyperemic  treatment. 

Surgeons  will  act  wisely  by  adding  the  regular  daily  use 
of  the  lung-suction  mask  (see  page  176)  to  the  protracted 
treatment  of  patients  afflicted  with  Pott's  or  hip-joint  dis- 
ease or  other  chronic  bone  troubles. 

Tuberculosis  of      The  same  method  of  treatment  is  to  be  employed  in  the 
the    Ilio-sacral        .  .  .  . 

Joint  and  of  the  serious  cases  of  unilateral  or  bilateral  tuberculous  affection  of 

Sacrum.        ^Yiq  ilio-sacral  joint*  and  of  the  intractable  tuberculosis  of 

the  OS  sacrum.    If  such  patients  have  the  means,  they  should 

go  to  the  mountains,  accompanied  by  a  competent  and 

thoroughly    instructed   nurse,    and    remain    there   under 

medical  superintendence.     (Figs.  84  and  85.) 

It  is  to  be  hoped  that  sanatoria  for  the  poor  will  soon  find 
sufficient  financial  support  to  enable  them  to  open  their  doors 
also  to  adult  patients  suffering  from  surgical  tuberculosis, 
even  if  their  trouble  be  complicated  with  sinus-formation. 

A  patient  with  this  form  of  tuberculosis  may  be  up  and 
about,  if  he  wear  a  movable  corset  and  use  crutches  to 
support  the  weight  of  the  upper  part  of  the  body. 

Case. — Male,  forty;  pulmonary  tuberculosis;  tubercu- 
lous inflammation  of  sheath  of  left  Achilles  tendon;  cold 
abscess  over  left  ilio-sacral  articulation.  Elastic  bandage 
around  thigh  twenty-two  out  of  the  twenty-four  hours 
for  the  tendon-sheath  affection.  Abscess  evacuated  with 
trocar  three  times  and  injected  with  5  per  cent,  sterilized 
emulsion  of  iodoform  glycerin;  sinus  formation.  Sent  to 
mountains  with  nurse;  general  regime.  Tuberculin  plus 
hyperemic  treatment;  daily  suction  hyperemia  over 
sacrum.  Ten  months  later  sinus  closed;  tendon  trouble 
cured,  but  affection  of  opposite  ilio-sacral  joint  becomes 
apparent;  tenderness  over  fifth  lumbar  vertebra.  Diag- 
nosis :  tuberculosis  of  entire  upper  portion  of  the  os  sacrum 
involving  fifth  lumbar  vertebra.  Leather  corset.  Large 
cold  abscess  in  right  groin  slowly  develops.     Tapped  at 

*In  unilateral  disease  of  younger  or  middle-aged  patients  radical 
excision  of  this  joint  often  gives  good  results. 


TUBERCULOSIS. 


147 


two  different  times,  followed  by  injection  of  sterilized 
5  i)er  cent,  iodoforni-glycerin  emulsion.  Suction  treat- 
ment over  upper  part  of  the  os  sacrum,  both  sacro-iliac 
articulations,  and  the  two  lower  lumbar  vertebrae  faithfully 
continued.  Use  of  lung-suction  mask  added  twice  a  day 
for  one  hour  (see  p.  176)  in  order  to  increase  leukocy- 
tosis and  improve  general  condition  of  the  blood.     After 


Fig.  84. — Shows  the  appHcation  at  the  moment  when  the  attendant 
produces  the  local  hyperemia  by  rarefying  the  air  within  the  cup  by 
means  of  a  suction  pump.  The  large  cup  covers  the  upper  part  of  the 
sacral  bone,  the  fifth  and  fourth  lumbar  vertebrae,  and  both  ilio-sacral 
joints. 

two  years  of  uninterrupted  local  plus  fresh-air  treatment: 
bone  affection  thoroughly  healed;  patient  walks  many 
hours  without  support;  stoops  easily;  excellent  general 
condition. 

One  of  the  first  questions  that  arise  is,  whether  the  treat- 
ment is  applicable  to  all  joints,  excepting,  of  course,  the 


148 


BIERS    HYPEREMIC   TREATMENT. 


Contraindica-     hip-jomt,  which  presents  mechanical  obstacles  which,  so 

tion  to  the  Use 

of  Hyperemia  in  far,  have  not  been  overcome.     The  answer  is  a  negative 

the     Treatment 

of  Tuberculous  one.     ihere  are  exceptions,  namely: 

1.  The  purely  hydropic  forms  of  tuberculosis,  principally 

in  connection  with  the  knee-joint,  the  so-called  "synovitis 

tuberculosa  exsudativa."     Experience  has  showTi  the  old 


Fig.  85. — Demonstrates  the  cup  in  use.  After  the  proper  decree 
of  negative  pressure  within  the  glass  has  been  obtained,  the  suction 
pump  may,  of  course,  be  detached. 

method  of  aspiration,  follow^ed  by  the  injection  of  iodoform- 
glycerin,  to  be  preferable. 

2.  In  cases  of  which  we  know  that  the  functional  result 
cannot,  in  the  end,  be  superior  to  that  obtainable  by  resec- 
tion in  a  much  shorter  time;  e.  g.,  tuberculous  fistulous 
knee  affection  with  bony  adhesions  between  the  patella 
and  the  femur,  or  subluxation  of  the  tibia.     Such  a  joint 


TUBERCULOSIS.  149 

can  never  become  sufficiently  movable  to  give  the  patient 
a  feeling  of  security  as  regards  the  use  of  the  extremity. 
Here  resection  is  clearly  indicated. 

Especially  with  reference  to  the  knee,  then,  the  surgeon 
must  bear  in  mind  that  the  conservative  treatment,  re- 
quiring considerably  more  time,  should  not  be  employed 
except  it  promises  a  good  functional  result.  A  movable 
articulation  being  the  prime  advantage  of  the  method, 
it  should  not  be  applied  in  cases  in  which  this  is  not  likely 
to  be  obtained.  He  may  here  often  find  the  indication 
for  resection,  although  it  should  be  mentioned  that  resec- 
tion is  not  a  panacea  either.  Fistulous  cases  in  particular 
often  refuse  to  close.  However,  if,  then,  obstructive 
hyperemia  either  by  means  of  the  elastic  bandage  or  suction 
cups  be  employed  as  an  adjunct  to  resection,  the  trouble 
is  usually  overcome  in  a  most  gratifying  manner. 

With  the  ankle-joint,  elbow,  and  wrist  the  case  is  differ- 
ent. Here  we  may  expect  a  cure  with  a  good  functional 
result  in  about  75  per  cent,  of  the  cases,  more  or  less, 
from  the  use  of  Bier's  hyperemic  treatment. 

3.  Complicating  advanced  pulmonary  tuberculosis,  or 
amyloid  degeneration.     Here  amputation  is  indicated. 

With  the  exception  of  these  three  classes  of  tuberculosis, 
the  painless  and  conservative  Bier  treatment  is  indicated 
in  almost  every  case  of  joint  tuberculosis,  even  those  of 
severe  character. 

Advanced  age  is  no  contraindication.  There  is  no 
reason  why  old  people  should  not  as  well  benefit  from  Bier's 
beneficent  procedure. 

If  no  improvement  is  noted  after  a  few  weeks'  faithful  ap- 
plication of  the  method,  resection  or  amputation  is  in  order. 


150  bier's  hyperemic  treatment. 

Ambulatory  In  the  protracted  treatment  of  tuberculous  joint  disease, 

Treatment. 

either  by  bandage  or  suction  glasses,  the  patient  (or  his 

relatives)  should  be  taught  to  carry  out  the  treatment 

himself.    A  few  weeks'  stay  at  the  hospital  usually  suffices 

for   proper   training  in   this   direction.     If   the   patient's 

attention  is  earnestly  and  repeatedly  called  to  it,  he  will 

soon  understand  the  importance  of  perfect  cleanliness  in 

dealing  with  sinuses. 

Tuberculosis  of  the  upper  extremity  is  especially  well 
adapted  for  dispensary  practice.  Only  severe  cases  will 
need  to  go  to  a  hospital  for  a  longer  or  shorter  period. 
They  must,  however,  be  cautioned  to  come  for  regular 
frequent  revision,  and  to  promptly  report  in  the  event  of 
any  aggravation  of  the  trouble.  The  possible  development 
of  a  cold  abscess  must  be  carefully  watched  for  by  the 
surgeon. 

Adults  with  tuberculosis  of  the  lower  extremities  ought 
to  enter  a  hospital,  at  least  for  a  time.  As  stated  above, 
they  need  supporting  splints  after  improvement  has 
sufficiently  advanced  to  aUow  them  to  be  out  of  bed.  It 
is  important  not  to  have  these  patients  stay  at  the  hospital 
any  longer  than  is  absolutely  necessary,  for  they  onh'' 
fill  our  surgical  wards  with  non-operative  cases.  Besides, 
the  daily  observation  of  these  cases  is  rather  tiresome  in 
view  of  their  slow  progress.  At  the  dispensaries,  however, 
where  the  surgeon  sees  them  only  now  and  then,  they  will 
not  so  easily  wear  out  his  patience;  the  improvement 
during  the  longer  intervals  will  be  more  evident ;  and  last, 
but  not  least,  the  patients  themselves  are  much  better  off 
away  from  the  constant  suggestion  and  association  with  dis- 
ease as  necessarily  presented  in  the  wards  of  our  hospitals. 


TUBERCULOSIS.  151 

It  seems  hardly  necessary  to  say  that  the  hyperemic 
treatment  must  be  continued  steadily,  until  every  trace 
of  tuberculous  inflammation  has  disappeared. 

In  cases  in  which  the  stiffness  of  the  joints  persists  for 
months  after  a  cure  of  the  tuberculous  process  has  been 
effected,  a  carefully  conducted  hot-air  treatment  may 
bring  improvement, 

Most  remarkable  results  from  Bier's  hyperemic  treatment 
have  been  observed  in  cases  in  which  the  method  was 
applied  at  an  early  stage  of  the  disease.  It  is  evident, 
therefore,  that  an  early  diagnosis  is  of  the  utmost  impor- 
tance. 

It  is  also  essential  that  the  general  practitioner  become 
thoroughly  familiar  with  the  procedure,  for  such  cases  may 
well  remain  under  his  observation.  Early  correct  diagnosis 
and  early  application  of  hyperemic  treatment  may  prevent 
much  hardship  among  his  patients. 

Of  course,  obstructive  hyperemia  is  not  a  panacea  and 
should  not  be  looked  upon  as  such,  but  experience  has 
shown  that  this  conservative  method  is  by  far  the  best 
means  at  our  disposal  for  the  treatment  of  tuberculous 
joints.  It  makes  for  success  in  the  simplest  way,  wdth 
a  minimum  of  risk,  and  is  connected  with  the  least  dis- 
comfort to  the  patient.  It  reduces  his  pains  instead  of 
adding  to  them;  it  heals  without  loss  of  function, 

2.  Tuberculosis  in  Various  Localities. — Whereas 
tuberculous  disease  of  the  epiphysis  of  the  bones  with 
secondary  joint  infection  is  very  prevalent,  that  of  the 
diaphysis  is  extremely  rare. 

The  bones  furnishing  the  greatest  contingent  in  this  Spina  Ventosa, 


152  bier's  hyperemic  treatment. 

direction  are  the  fingers  and  toes,  as  also  metacarpal  and 
metatarsal  bones.  If  in  these  cases  the  diseased  bones 
are  removed,  the  fingers  or  toes  are  generally  materially 
shortened;  if  nothing  be  done,  the  same  result  usually 
sets  in.  Obstructive  hyperemia  by  means  of  the  elastic 
bandage,  or  suction  glasses  for  the  entire  hand  or  foot, 
promises  a  more  favorable  outcome. 

Cold  abscesses  in  connection  with  this  trouble  are  incised 
as  usual,  and  then  the  hand  or  foot  is  subjected  to  suction. 
Tamponade  is  never  used. 

The  surgeon  who  prefers  to  combine  operative  with  Bier's 
treatment  may  open  the  diseased  bone,  clean  out  the  tuber- 
culous deposits  and  then  start  the  hyperemic  treatment, — 
again  without  employing  tamponade.  He  will  often 
hasten  convalescence  in  this  way.  An  x-ray  photograph 
taken  primarily  is  of  great  help  in  estimating  the  extent 
of  the  trouble. 

Certainly,  the  necessity  of  transplanting  a  piece  of  the 

corticalis  of  the  tibia  with  its  periosteum  into  the  defect 

resulting  from  radical   operation  for   spina  ventosa  will 

rarely  arise,   either  after  hyperemic  treatment  alone  or 

when  used  in  conjunction  with  the  cleaning  out  of  the 

central  osseal  canal. 

Abscesses    Due      Qold  abscesses  due  to  the  softening  form  of  tuberculous 
to   Tuberculous  ^ 

Glands.  lymphadenitis,  can  rarely  be  attacked  to  advantage  by 

radical  operation.  A  small  incision  and  the  regular  use 
of  the  suction  glass  for  the  production  of  the  required 
hyperemia  will  hasten  the  breaking  down  of  the  remnant 
of  the  gland,  which  latter  is  then  aspirated  through  the 
opening.  Suction  is  continued  until  the  fistula  has  closed. 
This  treatment  is  of  special  value  in  cases  in  which  the 


TUBERCULOSIS.  153 

cosmetic  result  is  a  consideration.  If  suppurating  glands 
in  the  upper  part  of  the  neck  are  thus  treated,  the  elastic 
neck-band  should  be  worn  in  addition  during  the  course  of 
the  night,  sometimes  also  part  of  the  day. 

Tuberculous  glands  that  have  no  tendency  to  become 
softened,  can  be  but  little  benefited  by  hyperemic  treat- 
ment.    They  have  to  be  extirpated. 

Cold  abscesses  as  we  find  them  above  or  below  Poupart's  Wandering 

Cold  Abscesses, 
ligament,  as  a  result  of  some  tuberculous  process  of  the 

ribs  or  vertebrae,  should  not  be  treated  by  incision  and 

suction.     These  it  must  he  the  surgeon's  aim  to  keep  dosed. 

Aspiration,  followed  by  the  injection  of  a  sterilized  five  (or 

ten)  per  cent,  iodoform-glycerin  emulsion,  should  be  done  and 

repeated,  if  necessary.     If  perforation  has  already  occurred 

at  the  time  when  the  patient  comes  for  treatment,  suction 

hyperemia  may  prevent  or  improve  a  mixed  infection. 

Injection  of  the  liquefied  bismuth  paste  as  advised  by 

Emil  Beck,  of  Chicago,  represents  a  most  recommendable 

and  promising  form  of  treatment  in  the  latter  class  of  cases. 

Tuberculosis  of  the  testicle  has  also  been  successfully  Tuberculosis  of 

the  Testicle, 
treated  by  hyperemic  treatment. 

The  technique  has  been  mentioned  above.  Obstructive 
hyperemia  is  produced  with  the  help  of  a  soft  elastic  tube 
(not  of  too  small  caliber)  placed  around  the  root  of  the 
scrotum  and  tied,  or  fastened  by  a  small  clamp.  (Figs. 
11  and  12.)  A  narrow  pad  of  cotton  batting  should  be 
slipped  underneath  the  tube  (Fig.  86),  which  is  to  remain 
in  place  for  one  to  two  hours  twice  a  day,  or  longer,  accord- 
ing to  prescription.  Here  again  the  proper  dosage  best 
adapted  to  the  case  must  be  found  by  observation. 

In  unilateral  affection  the  diseased  testicle  alone  may  be 


154 


BIER  S    HYPEREMIC   TREAT.MEXT. 


submitted  to  treatment.  Usually,  the  patients  prefer  to 
have  the  tube  encircle  the  entire  basis  of  the  scrotum,  thus 
placing  the  diseased  and  healthy  organ  under  hyperemia. 
No  harm  has  ever  resulted  therefrom. 

Cold  abscesses  are  opened  and  subjected  to  suction,  best 
while  the  tube  is  not  in  place.     (Fig.  87.)     With  correct 


Fig.  86. — Shows  the  elastic  tube  in  position,  ready  to  be  tied  by  the 

attendant. 

technique  the  pains  are  soon  relieved;  the  infiltration  of 
the  epididymis  slowly  decreases  or,  if  it  breaks  down,  is 
partly  discharged  into  a  cold  abscess,  and  then  through 
the  sinus,  that  is  to  form  after  the  abscess  has  been  incised 
and  emptied.  Aseptic  treatment  of  such  sinuses  is,  of 
course,  strictly  to  be  observed.  Patients  learn  easily  to 
apply  the  tube  themselves.    Their  own  feeling  will  be  the 


TUBERCULOSIS.  155 

best  guide  in  indicating  the  degree  of  firmness  with  which 


Fig.  ST. — For  description  see  case  given  on  page  156. 


-_.""-  "''^^v 


Fig.  88. — For  details  see  case  given  on  page  156. 

it  should  be  applied.     If  suction  cups  are  to  be  used, 
these,  too,  can  be  well  handled  by  the  patient  himself. 


156  bier's  hyperemic  treatment. 

Those   who  can   afford   it,  may  employ  a  special   nurse 
for  this  purpose.     (Figs.  86-88.) 

Case:  Forty-nine  years;  double  tubercular  epididymitis;  very 
voluminous  infiltration  on  left  side,  embracing  testicle  like  collar- 
ette; broke  down  at  lower  pole  ten  days  after  beginning  of  hyperemic 
treatment.  Sinus  regularly  subjected  to  suction  hyperemia;  good 
result  (Figs.  87,  88).  Secretion  scant  and  serous;  skin  not  under- 
mined. Some  cheesy  material  comes  away;  on  right  side  but  one 
circumscribed  nodule,  of  cherr\''s  size.  Vas  deferens  not  infiltrated 
on  either  side.  Prostate  and  urinary  system  not  involved.  Typical 
case  of  ascending  tuberculosis.  After  one  year's  faithfully  conducted 
hyperemic  treatment,  changing  prescription  for  application  from  time 
to  time,  the  left  broken-down  epididymis  is  almost  of  normal  size;  a 
very  minute  sinus  is  still  present;  discharge  usually  serous,  never 
viscid;  for  a  short  time,  during  a  further  breaking-down  of  the  in- 
filtration it  was  purulent.  The  circumscribed  nodule  on  the  right 
side  has  changed  very  little,  if  any,  in  size,  but  is  considerably  harder 
in  consistency  (transformation  into  connective  tissue).  No  infiltra- 
tion of  vas  deferens;  no  frequent  micturition;  no  pain;  urine  normal. 
The  patient  who  has  used  the  lung  suction  mask  regularly  twice  per 
day  during  the  last  twelve  months,  and  has  thereby  gained  over  one 
inch  in  chest-circumference,  is  in  excellent  general  condition;  ultimate 
cure  with  retention  of  both  testicles  seems  assured. 

Between   treatments   a   suspensory   bandage   is   worn. 
In  the  presence  of  a  sinus,  a  piece  of  sterile  gauze,  thus: 


must  first  cover  the  scrotum. 


It  should  be  stated  that  the  swelling  of  the  epididymis 
rarely  disappears.  Infiltrated  nodules  persist;  but  these 
are  made  up  by  connective  tissue  and  do  no  longer  contain 
tubercles.  It  has  been  seen  that  the  persistence  of  these 
nodules,  even  as  far  as  their  size  is  concerned,  does  not 
disprove  the  success  of  the  treatment,  so  long  as  the  pains 
disappear  and  the  progress  of  the  disease  is  checked. 

In  these  cases  again  the  hyperemic  treatment  yields 
best  results  if  applied   in  the  beginning  of   the  disease. 


TUBERCULOSIS.  157 

It  is  indicated  if  both  sides  are  affected,  or  if  one  testicle  has 
already  been  removed. 

Bilateral  castration  should  always  be  the  last  resort, 
unless  the  patient  himself  prefer  an  operation  to  a  long- 
continued  treatment  which,  of  course,  does  not  absolutely 
guarantee  a  cure.  In  such  a  case  resection  of  the  epididy- 
mis, though  doubtful  in  its  effect  and  value,  might  first 
be  undertaken.  For  a  secondary  infection  of  the  testicle 
proper,  as  found  in  a  number  of  cases  in  the  course  of  the 
operation  by  orchidotomy,  hyperemic  treatment  might 
then  be  tried. 

Before  total  emasculation  is  carried  out,  the  patient 
and  his  relatives  should  be  made  aware  of  the  importance 
of  internal  testicular  secretion;  they  should  be  told  that 
mental  disturbance  of  some  kind  or  other  not  infrequently 
follows  this  procedure. 

Unilateral  orchidectomy,  however,  seems  advisable  in 
all  cases  in  which  only  one  epididymis  is  the  seat  of  an 
advanced  suppurating  tuberculous  infection,  so  that  the 
mate  might  be  saved. 

It  is  self-understood,  that  our  advice  to  the  patient 
must  be  based  upon  a  most  careful  diagnosis  of  the  condi- 
tion of  the  genito-urinary  tract.  If  tuberculosis  of  the 
epididymis  is  but  a  part  of  a  more  generalized  tuberculous 
affection,  involving  vas  deferens,  seminal  vesicles  and 
prostate,  or  kidney  and  bladder,  neither  operative  nor 
hyperemic  treatment  can  hold  out  much  hope  for  extensive 
improvement.  Still,  we  shall  probably  feel  inclined  to  put 
such  a  patient  under  good  hygienic  regime,  as  far  as 
financial  circumstances  permit,  and  combine  with  this  an 
attempt  at  preserving  the  diseased  generative  glands. 


158 


BIER  S    HYPEREMIC    TRF:ATMEXT. 


Tuberculosis  of 
Tendon-sheaths 
and  Synovial 
Tendon  Sacs 
(Tuberculous 
Hygroma). 


Tuberculous 
Infiltration 
within  Soft 
Tissues. 


Tuberculosis  of  the  tendon-sheaths  of  forearm  and  foot, 
as  also  of  synovial  sacs  (hygroma),  is  treated  with  the  elastic 
bandage  in  the  same  manner  as  tuberculous  joints.  The 
serous  exudation,  so  often  present  and  usually  somewhat 
turbid,  is  first  removed  by  puncture.  The  so-called 
"rice-corpuscles,"  found  in  the  hour-glass-shaped  synovial 
sac  in  the  palm  of  the  hand  and  under  the  volar  carpal 
ligament,  must  also  be  primarily  removed.  They  are 
never  preserved  under  conservative  treatment.  The  sac, 
therefore,  is  opened  by  a  small  incision,  best  in  the  palm 
of  the  hand,  and,  after  its  contents  are  thoroughly  evacu- 
ated by  massaging  and  gently  squeezing  the  sac  over 
toward  the  wound,  is  either  closed  again  by  suture,  or, 
if  one  is  not  sure  that  all  the  corpuscles  have  been  removed, 
is  left  open  and  dressed.  Then  artificial  hyperemia  is 
started  and  given  twice  a  day  for  one  to  two  hours.  Here 
again  attention  must  be  called  to  the  fact  that  this  con- 
servative procedure  has  to  be  continued  for  a  long  period 
of  time.  However,  the  results  often  are  ideal.  If,  on  the 
other  hand,  it  be  a  question  of  saving  time,  operation 
should  be  done;  and  we  know  that  radical  extirpation  of 
the  fungous  synovial  sheaths  with  immediate  suture  of 
the  wound,  under  artificial  anemia,  is  often  followed  by 
primary  union,  with  excellent  preservation  of  function, 
although  these  satisfactory  results  are  less  frequently 
encountered  in  tuberculous  affections  of  the  flexor,  than 
of  the  extensor  sheaths. 

Now  and  then  tuberculous  infiltrations  of  soft  tissues, 
not  dependent  on  bone-  or  joint-  or  glandular  affection, 
are  met  with  in  different  parts  of  the  body.  This  trouble 
yields    beautifully    to    hj^peremic    treatment.     Especially 


TUBERCULOSIS.  159 

if  occurring  in  prominent  parts  (face),  the  use  of  the  elastic 
neck-band  is  invahiable,  in  view  of  the  often  remarkable 
cosmetic  results.  If  ai)plie(l  in  time,  breaking-down  of 
the  infiltration,  with  the  inevital:)le  cold-abscess  formation, 
can  be  successfully  averted. 

Case. — Girl,  twenty-one  months;  for  the  last  six  weeks 
increasing  diffuse,  bluish-red,  tender  infiltration  of  left 
cheek,  the  size  of  a  child's  palm;  beginning  softening 
of  the  skin.  Pronounced  tuberculous  family  history. 
Elastic  neck-band  twice,  ten  hours  per  day.  Mother 
and  nurse  instructed.  Three  weeks  later,  focus  reduced 
to  a])out  one-sixth  of  former  size;  after  two  more  weeks 
infiltration  entirely  absorbed.     Cheek  normal. 

In  cases  of  external  incomplete  fistula  in  ano,  consecu-  incomplete 
tive  to  the  perforation  or  an  incision  of  a  tuberculous  ^^^^ula  in  Ano. 
abscess,  in  which  operation  is  refused,  the  suction  glasses 
may  well  be  tried.  Application:  twice  per  day  for  forty- 
five  minutes.  Also  the  very  minute  communication  with 
the  rectum  that  is  usually  present  in  these  cases,  although 
the  probe  refuses  to  pass,  can  be  definitely  closed  if  the 
treatment  be  continued  long  enough. 

Between  the  treatments  an  ointment  dressing  covers 
the  wound.     Sitz-baths  are  ordered. 

It  need  hardly  be  stated  that  in  cases  of  complete  anal 
fistula  hyperemic  treatment  should  not  be  attempted. 

In  view  of  what  we  have  learned  about  hyperemia,  it  Tuberculosis  of 
would  seem  that  the  curative  effect  of  abdominal  section  the  Peritoneum, 
in  exudative  tubercular  peritonitis,  the  cause  of  which 
has  been  so  long  disputed,  is  due,  principally,  to  the  hyper- 
emia following  the  evacuation  of  the  fluid  present.  This 
reasoning  would  also  explain  the  fact  that  the  hyperplastic 
types,  in  which  the  vessels  cannot  dilate  to  any  consider- 
able extent,  rarely  respond  to  this  procedure.  Remark- 
able, of  course,  remains  the  circumstance,  that  a  single 
induction  of  a  hyperemia  should  prove  curative.     Yet, 


160  bier's  hyperemic  treatment. 

as  observation  has  shown  over  and  over  agam,  immediate 
closure  of  the  wound  after  abdominal  section  is  usually 
followed  by  a  permanent  cure.  Of  course,  we  are  unable 
to  tell  how  long  the  ensuing  hyperemia  lasts. 

In  closing  the  chapter  on  infectious  inflammations,  it 
would  seem  proper  to  here  repeat  the  principal  features 
of  hyperemia  in  general,  viz. : 

The  painlessness  of  its  application,  no  matter  which 
form  of  hyperemia  may  be  employed; 

Its  power  of  promptly  relieving  already  present  pain; 
and,  if  it  come  to  operative  intervention : 

The  good  cosmetic  result  generally  obtained  under  its 
use;  and,  last,  but  not  least. 

Its  great  tendency  to  preserve  the  function  of  the 
affected  part. 

Syphilis. 
It  has  been  interesting  to  note  that  artificial  hyperemia 
is  void  of  any  special  value  in  the  treatment  of  syphilitic 
lesions.  Evidently,  the  pathologic  changes  brought  about 
in  the  body  by  the  spirochata  pallida  (Schaudinn)  do 
not  react  to  this  mode  of  attack.  This  lack  of  response  to 
hyperemia  is  so  definite  that  it  has  been  suggested  that 
the  negative  or  positive  result  of  Bier's  treatment  might  be- 
come another  decisive  factor  in  the  case  of  a  differential 
diagnosis.  However,  this  is  merely  a  suggestion,  and 
further  investigations  will  have  to  be  made  before  any  con- 
clusions can  be  drawn.  Perhaps  it  will  be  shown  that  hyper- 
emic treatment  in  combination  with  the  usual  antisyphilitic 
regime  will  more  speedily  bring  into  subjection  and  to 
absorption  such  syphilitic  lesions  of  the  third  stage  as  have 
proven  very  obstinate  to  any  kind  of  treatment  (e.  g., 
specific  osteoperiostitis  of  the  tibia,  syphilis  of  the  brain, 
etc.),  as  well  as  hasten  recovery  in  those  cases  that  are 


CHRONIC    ARTHRITIS.  161 

known  to  yield  only  to  prolonged  mercurial  and  iodine 
medication. 

For  the  specific  ulcer  of  the  leg  this  proof  has  already 
been  rendered.  Obstructive  hyperemia  with  the  elastic 
bandage  around  the  thigh  will  often  help  along  in  a  sur- 
prising manner  the  cleansing  of  sloughing  ulcerations  and 
their  subsequent  cicatrization. 

CHRONIC    INFLAMMATIONS    NOT    DUE    TO    SPECIFIC 
BACTERIA. 

Chronic  Arthritis  (Chronic  Articular  Rheumatism);    Ar- 
thritis DEFORMANS;  ARTHRITIS  URICA  (GOUT). 

Appendix:  Joint  Stiffness,  Following  Inflammation. 

The  nomenclature  of  these  troubles  is  very  much  mixed 

up.     Still,  the  above  subdivision  would  seem  permissible 

in  the  face  of  clinical  experience. 

Active  hyperemia  by  means  of  hot  air  is  the  treatment  Chronic  Arthri- 
tis (Chronic 
for  this  trouble.     It  has  a  powerful  influence  in  causing  Articular  Rheu- 

inflammatory  exudates  to  become  absorbed.  However, 
it  greatly  taxes  the  patient's  strength,  at  least  in  the 
severe  cases  with  involvement  of  many  joints.  Here, 
then,  the  physician  must  proceed  very  cautiously.  Only 
the  joints  principally  affected  should  be  exposed  to  the 
hot  air,  one  or  two  joints  of  the  upper  extremities  in  the 
morning  and  the  same  number  of  joints  of  the  lower  ex- 
tremities in  the  afternoon.  Time:  one-half  to  one  hour 
daily.  Degree:  as  hot  as  can  be  conveniently  borne. 
Dosage:  to  be  adapted  to  the  patient's  physical  endurance. 

Incidentally,  the  interesting  observation  has  been  made 
that  by  thus  treating  the  mainly  affected  joints  other 
joints  also  improve. 

The  treatment  is  continued  until  a  cure  is  obtained. 
11 


162  bier's  hyperemic  treatment. 

It  should  be  mentioned  that  also  obstructive  hyperemia 
(with  the  elastic  bandage)  may  prove  of  great  benefit  in 
this  affection,  particularly  in  combating  the  acute  exacer- 
bations which  patients  of  this  kind  so  often  are  subject  to. 
Especially  true  is  this  of  the  cases  in  which  the  smaller 
joints  are  involved;  e.  g.,  elbow,  wrist  and  finger  articula- 
tions. Tlie  bandage  is  applied  from  ten  to  eleven  hours 
twice  per  day,  with  the  usual  one  to  two  hours'  intermission. 
The  resulting  edema  should  be  reduced  by  rubbing  and 
elevation.  Scientific  massage  is  not  required  for  this 
purpose.  The  edema,  of  course,  cannot  be  removed  by 
passive  hyperemia;  this  only  improves  the  stiffened  con- 
dition. But  the  elastic  compression  must  be  strong 
enough  to  produce  this  very  edema  in  the  parts  below; 
otherwise  it  is  of  little  benefit. 

In  some  cases,  particularly  knee  cases,  passive  hyperemia 
has  shown  such  remarkably  good  results  that  some  surgeons 
have  come  to  consider  the  majority  of  cases  of  chronic 
articular  rheumatism  to  be  dependent  upon  a  former 
gonorrheal  infection  of  mild  type.  In  fact,  the  disease 
sometimes  develops  as  a  result  of  a  previous  acute  gon- 
orrheic  inflammation  that  was  successfully  overcome. 

Patients  suffering  from  chronic  rheumatism  of  the 
shoulder  may  be  greatly  benefited  by  the  systematic  use 
of  the  hot-air  box  for  the  shoulder,  as  shown  in  Figs.  56 
and  57.  Many  confirmed  rheumatics  procure  such  an 
apparatus  for  their  own  private  use  and  succeed  in  prevent- 
ing the  full  development  of  a  recurring  attack  by  promptly 
employing  this  apparatus. 

Arthritis  De-         Arthritis  deformans  has  been  treated  with  hot  air  with 
formans.  .  i      i  •  r    i 

varymg   success.     Pronounced   destruction   of   bone   and 

cartilage  can,  of  course,  not  be  rectified  by  it.     In  such 


JOINT    STIFFNESS    FOLLOWING    INFLAMMATION.        163 

cases  one  has  to  be  contented  with  alleviating  tlie  pain 

and  retarding  the  progress  of  the  trouble.     Active  motion 

and  the  use  of  the  limbs  should  be  insisted  upon.     Plaster 

splints  and  orthopedic  machines  that  put  the  joint  at  rest 

are  to  be  discarded. 

Attacks  of  gout  yield  nicely  to  passive  hyperemia.     The  Arthritis    Urica 

(Gout), 
bandage  is  applied  for  two  to  three  hours  twice  per  day. 

In  the  interval  alternating  hot  and  cold  local  applications 

are  said  to  be  of  benefit. 

It  is  interesting  to  note  that  inflammations  caused  by 

uric  acid  yield  to  the  influence  of  artificial  hyperemia  as 

readily    as    those    produced    by    bacterial    poisons.     The 

cause  of  the  inflammation  seems  to  be  immaterial. 

APPENDIX. 
JOINT  STIFFNESS  FOLLOWING  INFLAMMATION. 

The  doctor  who  has  earnestly  worked  for  maintenance 
of  function  in  treating  traumatically  inflamed  joints,  as 
described  above,  should  not  stop  half-way.  He  should 
try  to  overcome  the  last  vestige  of  stiffness  by  prescribing 
and  superintending  active  hyperemia  by  means  of  hot 
air  and  the  orthopedic  suction  apparatus  mentioned  above. 

It  is  evident  that  this  can  be  done  satisfactorily  in  hospi- 
tals and  clinics  only,  where  these  apparatus  are  on  hand 
and  their  working  is  thoroughly  understood. 

One  word  still  with  reference  to  the  "brisement  force,"  Brisement 

.   .  Force, 

which  seems  to  be  in  favor  with  many  physicians.  Ex- 
perience has  shown  that  while  mobility  is  temporarily 
increased  thereby,  the  blood  exudation,  caused,  later  in- 
creases the  ankylosis  owing  to  the  tight  new  formation  of 
connective  tissue.  This  procedure  is  never  practised  in 
connection  with  hyperemic  treatment. 


164 


BIER  S    HYPEREMIC   TREATMENT. 


Inflammatory 
Flat  Foot. 


Club-foot. 


VARIOUS  SURGICAL  DISEASES  THAT  ARE  BENEFITED  BY 
BIER'S  TREATMENT. 

Diseases  Belonging  to  the  Domain  of  Orthopedic  Surgery  : 
Inflammatory  Flat  Foot  and  Scoliosis. 

The  pathologic  changes  of  the  small  joints  of  the  tarsus, 

found  in  the  so-called  "inflammatory  flat  foot,"  respond 

most  favorably  to  the  hot-air  treatment.    The  resulting 


Fig.  89. — Apparatus  for  treating  pes  varus. 

marked  decrease  in  sensitiveness  soon  renders  possible 
active  and  passive  exercises.  Better  headway  is  generally 
made  by  this  procedure  than  by  the  forced  intermittent 
reposition  with  fixation,  which  may  insure  the  position, 
but  does  not  relieve  the  pain  and  stiffness. 

A  special  suction  apparatus  has  been  constructed  and 
used  with  great  success  in  reducing  congenital  pes  varus 


IXFLAMMATOIIY    FLAT    FOOT;  SCOLIOSIS.  165 

without  anesthesia  (Fraenkel,  assistant  to  Bier)  (Fig.  89). 
It  consists  of  a  strong,  large  ])ox  with  movable  lid  (a), 
carrying  glass  pane  (b),  used  as  a  window.  Foot  enters 
through  rubber  cuff  (c)  on  the  one  narrow  side,  it  is  gently 
steadied  in  a  comfortable  leather  stirrup  (d)  b}'  means 
of  strap  and  buckle  (e)  carried  across  the  dorsum  of  the 
foot.  Two  wire  cords  (/  and  g)  are  attached  to  the  stirrup 
and  run  over  castors  connecting  with  adhesive  plaster 
slings  which  surround  forefoot  (h)  and  leg  just  above  the 
malleoli  (i),  having  rotatory  effect.  The  lower  one  {h) 
abducts  and  pronates  the  foot,  the  upper  one  (i)  turns  the 
leg  inward  if  the  pump  (k)  is  worked.  The  increasing 
vacuum  induces  an  entirely  automatic  redressement  of  the 
deformity.  The  place  of  the  castors  can  be  changed  in  a 
vertical  as  well  as  a  horizontal  line  in  order  to  allow  of  the 
necessary  variation  in  the  direction  of  the  traction  re- 
quired. The  patient's  body  rests  on  a  seat,  w^hich  moves 
on  an  oblique  plane. 

Before  starting  the  suction  treatment  a  hot-air  bath  is 
given.     The  advantages  of  this  new  apparatus  are : 

1.  It  produces  the  redressement  without  manual  assis- 
tance in  the  physiologic  sense,  affecting  the  astragalo- 
calcaneal  articulation  as  well  as  Chopart's  joint;  incident- 
ally with  the  forefoot  the  calx  is  pressed  into  pronation, 
which  motion  is  hardly  obtainable  to  satisfaction  by  other 
means. 

2.  Rupturing  the  skin  of  the  sole  of  the  foot  or  fracture 
of  the  malleoli  is  rendered  impossible  by  virtue  of  the 
simultaneous  effect  of  the  hyperemia. 

3.  The  rotating  traction  also  effects  the  equinus-position 
of  the  foot. 

4.  The  pain-reducing  effect  of  the  hyperemia  renders 


Scoliosis. 


166 


BIER  s  hyp?:remic  treatment. 


general  anesthesia  superfluous,  even  in  cases  of  pronounced 
deformity.  Its  softening  influence  reduces  the  resistance 
not  onh'  of  the  muscles,  ligaments,  and  tendons,  but  also 
of  the  affected  bones. 

The  remaining  degrees  of  pes  equinus  and  excavatus 
are  treated  with  a  large  suction  glass,  as  shown  in  Fig. 


Fig.  90. — Illustrates  a  hot-air  box  in  which  a  number  of  scoliotic 
patients  can  be  simultaneously  treated  in  order  to  mobilize  the  stiffened 
vertebral  joints,  preparatory  to  the  gymnastic  exercises. 

44.     A  proper  movable  support  for  the  sole  increases  the 
effect  of  this  apparatus. 

Favorable  results  have  been  obtained  with  the  method 
in  the  treatment  of  lateral  curvature  of  the  spine.  Fig.  90 
illustrates  a  large  hot-air  chair  designed  for  the  use  of 
three  persons  of  various  size.  According  to  the  directions 
of  Klapp,  the  entire  spinal  column  is  exposed  to  hot  air, 
with  the  result  that   the  multiple  stiffened  articulations 


VARICOSE  veins;  ulcerations  of  leg.  167 

of  the  scoliotic  spine  gradually  become  mobilized;  this 
mobility  is  increased  by  immediately  following  up  the 
treatment  l)y  orthopedic  gj-nmastic  exercises. 

Varicose  Veins  ;  Ulcerations  of  the  Leg. 

Varicose  veins  and  their  sequelae  have  been  found  amen-  Varicose  Veins, 
able  to  active  (arterial)  hyperemia  only.  The  increased 
circulation  absorbs  the  chronic  edema  and  gradually 
overcomes  the  obstacles  to  proper  circulation  due  to  the 
thrombosed  veins.  The  treatment  is  especially  beneficial 
in  cases  showing  a  diffuse  ectasis  of  the  smaller  veins  of 
the  skin  with  the  subsequent  bluish,  edematous  swelling 
of  the  limb  and  foot;  as  also  in  cases  of  threatening  per- 
foration and  ulcer  formation. 

Time  of  exposure  and  degree  of  heat,  moderate,  about 
one-half  hour  daily  at  160°  F.  (70°  C).  Burns  must  be 
carefully  avoided,  as  they  would  only  mean  an  additional 
cause  for  ulceration. 

It  is  hardly  necessary  to  say  that  the  value  of  resection 
or  extirpation  of  the  saphenous  vein,  with  or  without 
Schede's  operation,  will  remain  unimpaired.  They  are 
indicated,  as  before,  in  cases  of  the  typical  varicose  en- 
largement of  the  trunk  of  the  vena  saphena. 

A  recent   thrombosis  constitutes   a  strict  contra-indica-  Recently 

Thrombosed 
tio7i  to  hot-air  treatment,  since  the  artificially  increased  Veins. 

circulation  would  be   apt   to  loosen   the   thrombus   and 

give  rise  to  the  always  threatening  pulmonary  embolism. 

With  perfected  organization  of  the  thrombus,  the  danger 

decreases. 

The  same  holds  good  in  thrombosis  of  the  femoral  vein, 

following   typhoid   and   other   infectious   diseases.     Here 

months  must  pass  before  hot-air  treatment  may  be  called 


168 


BIER  S    HYPEREMIC   TREATMENT, 


Ulcers  of  the 
Leg. 


into  action  to  assist  in  overcoming  the  troublesome  edema 
of  the  extremity. 

Ulcers  of  the  leg  yield  nicely  to  moderate  baking,  for 
one  and  one-half  hours  per  day.  Their  base  is  thereby 
quickly  cleansed  and  cicatrization  hastened.  The  method 
certainly  represents  a  valuable  addition  to  our  resources 
in  the  treatment  of  these  distressing  cases  that  often  crowd 
our  wards  and  tax  to  the  utmost  the  patience  of  both 
physician  and  patient.  Rest  in  bed,  with  proper  dressings, 
and  elastic  compression  over  the  wound  will  assist  in  hasten- 
ing the  course. 

We  would  here  again  call  attention  to  the  wisdom  of 
trying  obstructive  hyperemia  in  cases  of  chronic  syphilitic 
ulcer  of  the  leg,  in  the  absence  of  varicose  veins,  and  also  in 
cases  of  large  obstinate  ulcer  of  the  extremity  due  to  trau- 
matism. Often  these  latter  will  heal  to  a  certain  ex- 
tent when  contraction  with  cicatrization  stops  in  spite  of 
various  kinds  of  stimulating  dressings.  Only  Thiersch's 
skin  grafting  or  autoplasty  are  thus  far  known  to  have 
brought  them  to  a  close.  Passive  hyperemia  by  means 
of  the  elastic  bandage  (perhaps  also  the  suction  glass) 
offers  a  fair  chance  of  healing  them  without  operation. 


Senile  and 
Diabetic  Gan- 
grene; Gan- 
grene Due  to 
Embolism  of 
the  Main 
Artery. 


Senile  and  Diabetic  Gangrene  ?  Gangrene  Due  to  Embolism 
OF  THE  Main  Artery. 

It  is  very  tempting  to  locally  increase  the  quantity 

of  the  circulating  blood  in  cases  of  threatening  gangrene 

due  to  arteriosclerosis,  diabetes,  or   embolic  occlusion  of 

the  main  trunk  of  the  extremity  as  it  is  sometimes  seen  to 

follow  serious  cases  of  pneumonia,  etc.,  complicated  with 

endocarditis.     The  efficacy  of  such  procedure  has  been 


SENILE    AND    DIABETIC    GANGRENE.  169 

practically  demonstrated.  But  strict  supervision  and 
careful  handling  of  such  cases  are  absolute  requisites  to 
insure  success,  since  the  reduced  sensitiveness  of  the  parts 
and  sluggish  circulation  both  favor  burns. 

Ten  minutes'  exposure  to  hot  air  twice  per  day,  at  140°  F. 
(60°  C),  is  ample  for  the  beginning.  With  the  return  of 
warmth,  etc.,  to  the  extremity,  the  time  and  degree  of 
heat  may  be  slowly  increased  up  to  190°  to  195°  F.  (90°  C). 

Case. — Female,  sixty-four;  convalescent  from  severe 
attack  of  pleuro-pneumonia.  In  third  week  sudden 
intense  pain  in  left  arm;  pronounced  pallor,  soon  followed 
by  irregular  cyanosis;  no  radial  pulse;  sensation  absent. 
Diagnosis:  embolism  of  brachial  artery.  Hot-air  hypere- 
mia started,  first  twice,  then  three  times  a  day;  later  still, 
five  times  one  hour  per  day;  no  gangrene  of  part  of  ex- 
tremity; hand  perspires  freely;  pulse  and  sensation 
gradually  return.     Splendid  result. 

Should  the  same  therapy  employed  in  an  actually  present 
gangrene,  succeed  in  checking  its  progress,  a  continuation 
of  the  same  would  probably  favor  demarcation  and  separa- 
tion of  the  necrosed  part,  provided  amputation  is  not 
indicated. 

In  the  absence  of  facilities  for  hot-air  treatment  gentle 
obstructive  hyperemia,  for  two  hours  twice  per  day,  may 
answer  the  same  purpose.  The  bandage  should  be  applied 
over  an  area  where  the  femoral  or  brachial  artery  shows 
good  pulsation,  not  below  the  middle  of  the  thigh  or  arm, 
and  it  should  always  wander  up  and  down  the  extremity, 
as  previously  explained.  Great  care  is  needed  in  feeble 
diabetics,  as  pressure  gangrene  is  apt  to  appear  where 
the  bandage  has  been  in  place. 


170  bier's  hyperemic  treatment. 

Burns. 
Burns.  Artificial  hyperemia  has  been  advantageously  used  in 

mild  as  well  as  severe  burns.  The  beneficial  effect  of  the 
elastic  bandage  or  neck-band  in  these  cases  has  been  most 
striking  as  regards  the  almost  immediate  cessation  of  pain 
— a  factor  so  difficult  to  overcome  with  our  ordinary 
means.     Time  of  application  as  in  other  cases. 

It  is  advisable  to  continue  the  hyperemia  during  the  period 
of  skin  renewal.  The  subsequent  contraction  of  the  cica- 
trix is  less  marked  than  under  the  usual  treatment. 


Frost  Bites. 
Frost  Bites.  Hot-air  treatment  has  proved  of  great  benefit  in  frost 

bites.  Acute  and  chronic  cases  respond  equally  well  to 
it.  The  cyanosis  of  the  parts  involved,  the  troublesome 
paresthesias  and  ulcers  disappear  quickly  under  the  in- 
creased arterial  circulation.  An  ointment  dressing  should 
cover  the  ulcers  in  the  interval.  Passive  hyperemia,  too, 
has  shown  good  results  in  these  cases. 

Intraperitoneal       To    prevent    post- operative    intraperitoneal    adhesions 
Adhesions.         -^^  j^g^g  i^QQ^i  proposed  to  submit  the  patient's  abdominal 
region  to  hot-air  treatment  soon  after  the  operation. 


TUMORS. 

It  is  self -understood  that  tests  wdth  artificial  hyperemia 
in  malignant  disease  are  to  be  made  only  in  inoperable 
cases. 

The  elastic  bandage  which  has  been  tried  in  cases  of 
sarcoma,  has  given  unsatisfactory  results;  the  increased 
amount  of  blood  seemed  to  favor  rapid  proliferation  of  the 
tumor. 


bier's   hyperemia   IX    .MEDICINE.  171 

However,  the  results  from  hyperemia  by  means  of 
suction  glasses  have  been  rather  encouraging.  In  ten 
cases  of  inoperable  sarcoma  and  carcinoma  in  which  this 
treatment  has  been  employed  ("Miinchener  med.  Woch- 
enschr./'  No.  43,  p.  21  to  24,  1907)  diminution  in  the  size  of 
the  tumor  was  observed  in  every  instance,  and  the  longer 
the  treatment  had  been  applied  the  more  pronounced  was 
the  shrinkage.  Microscopic  examination  of  particles  of 
the  tumors  excised  after  treatment  showed  the  cancer 
cells  to  have  been  partly  replaced  by  granulation  tissue. 
One  case,  a  young  man  twenty  years  of  age  with  inoperable, 
undoubted  sarcoma  of  the  shoulder,  was  discharged  with 
no  visible  trace  of  the  disease  left,  after  a  prolonged  course 
of  suction  hyperemia,  and  without  the  tumor's  having 
undergone  softening  and  perforation. 

In  view  of  the  sad  prognosis  of  these  cases  of  inoperable 
malignant  disease,  the  method  seems  worthy  of  further 
trial. 


BIER'S  HYPEREMIA  IN  MEDICINE  AND  THE 
SPECIALTIES. 

With  the  value  of  artificial  hyperemia  in  the  treatment 
of  many  surgical  diseases  established  beyond  doubt, 
it  was  but  natural  that  a  therapeutic  agent  of  such  far- 
reaching  influence  should  have  been  tried  also  in  diseases 
belonging  to  the  domain  of  internal  medicine  and  the 
specialties.  In  many  respects  Bier  himself  was  again  the 
pathfinder  also  along  these  lines.  What  has  been  accom- 
plished thus  far  is  certainly  of  sufficient  interest  to  serve 
as  an  incentive  to  further  investigation. 

The  authors  of  this  book  consider  it  their  duty  to  give 
a  short  account  of  what  has  been  done  in  these  branches, 
indicating  by  the  smaller  type  used,  that  further  careful 
study  and  observation  are  needed  to  substantiate  the 
experiences  thus  far  reported. 


CHAPTER  V. 
HYPEREMIC  TREATMENT  IN  MEDICINE. 
Acute  Articular      Acute  articular  rheumatism,  being  similar  in  its  mani- 

Rneutnatistn.  '  ® 

festations  to  the  gonorrheic  affection,  like  the  latter  re- 
sponds well  to  artificial  hyperemia  by  means  of  the  elastic 
bandage.  Bier  was  the  first  to  try  his  method  in  this 
class  of  cases. 

Fairly  satisfactory  results  have  been  obtained  by  him 
as  well  as  others  under  adherence  to  the  following  rules : 

1.  The  bandage  is  applied  sufficiently  tight  to  produce 
redness  and  increased  warmth  of  the  part  treated,  but 
must  not  cause  edema. 

2.  Time  of  application:  twice  per  day  for  two  to  three 
hours. 

The  symptoms  disappear  in  the  following  order:  First, 
the  pain  ceases;  then  the  power  of  motion  shows  improve- 
ment, and  lastly  follows  reduction  of  swelling  and  fever; 
that  is  to  say,  the  most  serious  symptoms  yield  first. 

If  the  treatment  alone  does  not  relieve  the  symptoms 
within,  say,  a  week's  time,  salicylates  should  be  given  in 
addition,  but  in  smaller  doses  than  are  usually  administered 
in  these  cases.  No  harm  has  resulted  from  giving  the 
salicylates  at  once. 

It  may  be  taken  for  granted  that  cases  that  do  not  re- 
spond to  hyperemia  would,  likewise,  not  have  yielded  to 
salicylates. 

Hyperemia  should  always  be  tried  jirst  in  these  cases, 

172 


HYPEREMIC   TREATMENT    IN    MEDICINE,  173 

unless  the  patient  objects  to  this  mode  of  treatment  or 
the  spine  or  hip-joint  be  the  seat  of  the  trouble,  in  which 
event  hyperemia  can  be  induced  with  difficulty  only,  if 
at  all. 

Hyperemic  treatment  has  been  tried  in  the  various  forms  Cerebrospinal 
of  cerebrospinal  meningitis,  suppurative,  tuberculous  and 
epidemic. 

The  immediate  application  of  the  neck  band  has  been 
noted  to  overcome  symptoms  of  undoubted  beginning 
inflammation  of  the  meninges,  complicating  suppurative 
processes  of  the  skull  or  face. 

Passive  hyperemia  is  not  known  to  have  shown  any 
favorable  influence  in  cases  of  tuberculous  meningitis. 
But  in  the  epidemic  form  noteworthy  results  have  been 
obtained. 

Bier  suggested  some  time  ago  that  head  hyperemia 
plus  lumbar  puncture  might  be  worthy  of  trial,  inasmuch 
as  it  is  his  opinion  that  lumbar  puncture  not  only  reduces 
the  intracerebral  pressure,  but  also  evokes  a  hyperemia 
of  the  meninges,  same  as  puncture  of  a  pleuritic  effusion 
causes  hyperemia  of  the  pleura  and  that  of  an  ascites 
hyperemia  of  the  peritoneum. 

Five  cases  of  epidemic  cerebrospinal  meningitis  treated 
by  artificial  hyperemia  of  the  head  plus  lumbar  puncture 
have  been  recently  reported,  with  four  cures;  the  fifth,  a 
child  of  two  years,  at  the  end  of  the  ninth  week,  when  almost 
cured,  developed  symptoms  of  acute  hydrocephalus,  to 
which  complication  it  quickly  succumbed. 

This  favorable  experience  with  so  treacherous  a  disease 
should  invite  further  trials. 

The  result  in  36  cases  of  diphtheria  treated  with  hyper-  Diphtheria, 
emia  of  the  head  has  been:   more  rapid  loosening  of  the 
diphtheritic  membranes,  no  descent  of  the  process  into 
the  larynx,  and  no  subsequent  complications. 


174  bier's  hyperemic  treatment. 

It  is  self-understood  that  hyperemic  treatment  does  not 
constitute  a  contraindication  to  the  employment  of  anti- 
diphtheritic  serum. 

Pulmonary  The  idea  of  making  use  of  an  artificially  increased  volume 

Tuberculosis.  °  "^ 

of  blood  for  the  purpose  of  combating  surgical  tuberculosis 
was  conceived  by  Bier  as  a  result  of  his  studies  of  the 
observations  made  by  other  authors,  almost  a  century 
ago;  namely,  that  tuberculous  foci  are  found  with  great 
frequency  in  the  lungs  of  individuals  with  heart  lesions, 
causing  an  anemic  condition  of  the  lungs,  while  in  the 
presence  of  a  hyperemic  state  of  the  latter  they  are  rarely 
found. 

"Farre  and  Travers  (1815),  Lewis  (1826),  and  Frerichs 
(1853)  have  shown  by  numerous  postmortem  examina- 
tions that  patients  afflicted  with  stenosis  of  the  pulmonary 
artery  are  very  liable  to  be  stricken  with  phthisis,  whereas 
Rokitansky,  in  1838,  proved,  on  basis  of  his  large  dissec- 
tion material  at  the  Vienna  hospitals,  that  tuberculosis  of 
the  lungs  is  very  rarely  foimd  in  combination  with  venous 
pulmonary  hyperemia  such  as  is  observed  in  cases  of 
valvular  disease  of  the  heart  or  deviations  of  the  spinal 
column.  In  fact,  he  could  show  that  tuberculous  foci 
heal  and  show  all  the  characteristics  of  cicatrization  in  the 
presence  of  such  heart  lesions.  There  are  many  other 
interesting  proofs  of  the  fact  that  the  amount  of  blood 
within  the  lungs  determines  the  degree  of  liability  of  the 
patient  to  pulmonary  tuberculosis. 

It  seems  logical  to  assume  that,  if  nature  can  bring  to 
cicatrization  tuberculous  foci  in  the  lungs  by  reason  of  a 
hyperemia  existing  as  a  result  of  circulatory  disturbances, 
it  must  be  possible  to  obtain  the  same  result  by  means  of  a 
hyperemia  artificially  induced. 


HYPEREMIC    TREATMENT    IX    .MEDICINE.  175 

The  point,  then,  was  to  find  the  means  of  rehably  pro- 
ducing such  artificial  h^'peremia. 

Bier's  own  original  idea  (1903)  was  to  make  patients 
afflicted  with  pulmonary  tuberculosis  inhale  through  the 
nostrils  under  slight  compression  of  the  same  by  the 
fingers,  allowing  them  unobstructed  exhalation  through 
the  mouth:  (He  also  tried  to  produce  passive  hyperemia 
of  the  apices  of  the  lungs  by  glass  suction  apparatus  of 
various  sizes,  but  this  did  not  yet  prove  satisfactory.) 

We  know  that  the  respiratory  distention  and  contraction 
of  the  thorax  is  an  automatic  physiologic  act.  Xow,  if 
we  prevent  the  natural,  easy  inflation  of  the  elastic  lung 
tissue,  as  it  occurs  under  ordinary  circumstances,  when  the 
thorax  expands  during  the  act  of  inspiration,  the  air  within 
the  lungs  becomes  rarefied  and  blood  is  aspirated  from  the 
heart.  In  other  words,  we  produce  an  artificial  hyperemia 
of  the  lungs  by  suction. 

In  a  rather  crude  way,  obstructed  inspiration  could  also 
be  arranged  for  by  placing,  e.  g.,  eye-glasses  or  some  kind 
of  a  clamp  upon  the  nostrils,  regulating  the  degree  of 
obstruction  by  placing  same  higher  or  lower;  or  small 
perforated  corks  might  be  placed  within  the  nostrils,  the 
degree  of  obstruction  to  be  controlled  by  the  size  of  the 
perforations.  Empty  spools  with  holes  of  various  caliber, 
put  into  the  mouth  and  held  by  the  teeth,  the  lips  closing 
air-tight  around  the  spool,  will  obstruct  mouth  inspira- 
tion, while  expiration  can  then  take  place  freely  through  the 
angles  of  the  mouth,  alongside  the  spool,  the  lips  releasing 
their  hold  on  the  same.  This  latter  device  will  be  found 
rather  annoying  to  the  patient,  as  it  will  dry  out  the  mouth 
and  respiratory  passages. 

An  exact  regulation  of  the  degree  of  obstruction  to 
inspiration  can  be  obtained  with  the  so-called  ''lung 
suction  mask,"  devised  by  Kuhn.  Made  of  thin  celluloid, 
the  mask  has  the  shape  of  the  mouth-pieces  used  to  cover 


176 


BIER  S    HYPEREMIC   TREATMENT. 


the  patient's  face  when  administering  one  of  the  volatile 
drugs  for  general  anesthesia.  (Fig.  91.)  The  edges  here, 
too,  are  protected  by  rubber  tubing  which  is  filled  with 


Fig.  91. — Kuhn's  lung  suction  mask  for  the  hyperemic  treatment  of 
pulmonary  tuberculosis,  a,  Slide;  most  important  part,  inasmuch  as  it 
regulates  the  obstruction  to  inspiration,  d,  Slide,  situated  within  the 
mask,  shutting  off  communication  between  the  two  chambers  for 
mouth  and  nose.  It  is  always  kept  closed,  except  when  the  patient 
has  a  cold,  or  is  unable,  for  other  reasons,  to  inhale  through  the  nose, 
as,  e.  g.,  in  the  presence  of  polypi,  h  and  c  are  the  valves  which  serve 
for  expiration  and  prevent  additional  inspiration.  These  are  the  same 
as  those  usually  found  in  our  narcotising  apparatus.  This  model  of  a 
mask  is  very  practical,  inasmuch  as  it  can  be  used  for  the  face  of  any 
adult,  but  it  is  made  of  celluloid,  a  highly  combustible  material,  and 
cannot  be  sterilized  by  boiling,  drawbacks  which  call  for  correction. 
An  attempt  to  manufacture  the  mask  in  the  United  States  has,  thus  far, 
not  been  crowned  by  success,  there  being  a  patent  on  the  device.  A 
mask  of  smaller  size  is  made  for  children. 


HYPERE.MIC    TREATMENT    IX    MEDICINE.  177 

air  to  avoid  pressure.  The  mask  is  divided  transversely 
by  means  of  a  celluloid  wall  the  border  of  which  rests  on 
the  upper  lip  and  is,  likewise,  provided  with  an  inflatable 
pad.  In  this  way  we  have  two  separate  compartments, 
one  for  the  nose  and  one  for  the  mouth,  there  being  no 
communication  except  by  a  slide  covering  a  narrow  slit 
in  the  transverse  dividing  wall.     (Fig.  91,  d.) 

This  slit  is  opened  only  if  nasal  respiration  is  temporarily 
or  permanently  interfered  with.  The  mask  is  placed 
over  the  nose  and  mouth  of  the  patient  and  held  in  place 
by  two  elastic  straps  passing  below  the  ears  and  fastened 
in  the  back  by  means  of  a  buckle.  (Fig.  92.)  Another 
slide,  attached  to  the  outer  side  of  the  nasal  section  of  the 
mask,  controls  the  degree  of  obstruction  desired.  (Fig. 
91,  a.)  This  is  the  principal  part  of  the  device,  inasmuch 
as  by  it  we  regulate  at  will  and  by  degrees  the  amount 
of  obstruction  to  the  passage  of  air  into  the  alveoli  of  the 
lungs.  It  has  a  scale  of  6°,  and  covers  a  slit  somewhat 
less  than  one-sixteenth  of  an  inch  (one  millimeter)  wide 
and  somewhat  longer  than  the  one  in  the  partition  mem- 
brane between  mouth  and  nose  cavity.  Two  caps,  that 
can  be  screwed  off,  each  embracing  a  small  celluloid  plate, 
form  the  valve  for  expiration,  same  as  we  find  this  in  the 
ordinary  narcosis  inhalers.     (Fig.  91,  6  and  c.) 

If  the  regulating  slide  be  entirely  open,  the  patient 
can  inhale  quite  some  air,  but  naturally  never  as  much  as 
without  the  mask. 

Inspiration  is  done  through  the  nose  and  expiration 
either  through  the  mouth  alone  or  through  both  mouth 
and  nose. 

Of  course,  if  desired,  the  valve  over  the  mouth  section 
of  the  mask  could  be  entirely  removed.  But  this  should 
be  done  in  the  case  of  intelligent  patients  only,  as  then 
special  attention  has  to  be  paid  to  the  act  of  respiration. 
During  sleep  this  valve,  too,  should  always  be  in  place. 

12 


178 


BIER  S    HYPEREMIC    TREATMENT, 


The  mask  is  worn  in  the  beginning  two  to  three  times  a 
day  for  fifteen  minutes;  later,  the  time  is  slowly  increased 
to  one  hour  two  to  three  times  per  day.  The  primary  un- 
pleasant effects  from  wearing  the  mask,  consisting  in  head- 
ache and  dizziness,  will  not  last,  but  disappear  quickly 
as  the  applications  are  continued. 

While  using  the  mask  the  patient  would  best  rest  on 


Fig.  92. — Patient  resting,  with  the  lung-suction  mask  in  position. 
He  will  learn  to  use  it  for  one  hour  in  the  morning  and  one  hour  at  night, 
which  is  ample  for  the  average  case  and  does  not  interfere  with  the 
patient's  business.  The  couch,  of  course,  should  be  placed  as  near  an 
open  window  as  possible. 


an  easy  chair  on  the  piazza  or  on  a  lounge  near  an  open 
window,     (Fig.  92,) 

Disinfection  is  done  (with  the  rubber  straps  unbuckled) 
in  a  cold  three  per  cent,  solution  of  lysol  or  carbolic  acid. 
Afterward  the  mask  is  rinsed  in  cold  water  in  order  to  get 
rid  of  the  odor  of  these  disinfectants.  It  is  advisable  to 
remove  the  two  caps  on  top  of  the  mask  often  and  clean 


HYPEREMIC    TREATMENT    IX    MEDICINE.  179 

and  dry  the  small  celluloid  plates.  They  are  apt  to  be- 
come sticky,  but  proper  care  must  be  taken  to  always 
have  them  work  easily.  It  must  be  borne  in  mind  that 
celluloid  is  a  very  combustible  material  and  cannot  be 
disinfected  b}^  boiling. 
These  two  drawbacks  still  remain  to  be  overcome.* 
The  use  of  the  mask  is  not  known  to  have  done  harm. 
All  of  the  75  cases,  in  which  the  mask  is  so  far  reported  to 
have  been  used,  were  benefited.  No  deleterious  effects  of 
any  kind  were  observed. 

The  principal  effect  to  be  obtained  by  the  mask  is  two- 
fold: 

1.  The  healing  of  the  tuberculous  foci  within  the  lungs 
by  reason  of  the  hyperemia  produced. 

2.  The  increase  of  the  red  and  w^hite  blood  corpuscles 
as  well  as  of  hemoglobin  in  the  blood. 

So  far  clinical  observation  and  investigation  have  shown : 

1.  That  the  beneficial  influence  of  the  mask  is  greatest 
in  cases  of  incipient  pulmonary  tuberculosis,  or,  better 
still,  when  used  as  a  prophylactic. 

2.  That  also  advanced  cases  are  greatly  benefited  by 
it,  as  long  as  chronic  toxemia  and  pronounced  weakness  of 
the  heart  do  not  render  impossible  any  kind  of  improvement. 

3.  That  the  risk  of  hemorrhage  from  the  lungs  does 
not  forbid  its  use;  on  the  contrary,  there  seems  to  be  less 
liability  to  hemorrhage,  since  the  granulations  in  the  lung 
tissue  apparently  get  stronger  under  the  application  of 
the  mask,  same  as  we  observe  this  in  granulations  on  the 
surface  of  the  body,  while  under  hyperemic  treatment. 

4.  That  by  artificially  reducing  respiratory  expansion 
the  lungs  are  placed  at  rest,  an  important  point  in  the 
treatment  of  pulmonary  tuberculosis,  which  has  lately 
been  emphasized  by  various  authors. 

*  There  is  a  United  States  patent  upon  the  mask;  the  same,  how- 
ever, covers  only  the  manner  of  construction,  not  the  idea  of  obstructed 
inspiration  and  free  exhalation. 


180  bier's  hyperemic  treatment. 

5.  That  postmortem  observation  of  the  lungs  of  a  patient 
who  died  of  chronic  intestinal  tuberculosis  and  in  whom 
the  mask  had  been  used  for  several  months,  has  shown 
the  foci  isolated  and  surrounded  by  a  mass  of  new-formed 
connective  tissue,  the  latter  being  in  the  stage  of  cicatri- 
zation. Further  observations  of  pathologists  will  be  re- 
ceived with  great  interest. 

6.  That,  on  account  of  the  larger  quantity  of  blood 
being  aspirated  into  the  lungs,  more  oxygen  enters  the 
circulation;  furthermore,  that  in  consequence  of  the 
resistance  offered  to  inspiration,  the  entire  system  of 
respiratory  muscles  is  strengthened,  on  the  basis  of  the 
idea  underlying  the  well-known  "Swedish  movements" 
method. 

7.  That  by  thus  improving  the  constituency  of  the 
blood,  the  use  of  the  mask  not  only  incidentally  improves 
the  usual  anemia  of  phthisical  patients,  but  promises  to 
become  one  of  the  most  powerful  physical  aids,  so  far 
known  to  us,  in  our  fight  against  ordinary  anemia. 

8.  That,  according  to  the  degree  of  obstruction  to  inspira- 
tion arranged  for,  the  mask  produces  the  effect  of  various 
high  altitudes  on  the  general  system,  that  is  to  say,  it 
rapidly  increases  the  number  of  red  and  w^hite  blood  cor- 
puscles, of  the  latter  especially  the  polynuclear  neutrophiles, 
and  the  percentage  of  hemoglobin.  This  is  produced  by 
the  irritating  effect  of  the  condition  of  reduced  tension  of 
oxygen  in  the  blood  on  the  blood-producing  tissues  of  the 
body,  principally  on  the  bone-marrow. 

Inasmuch  as  the  increase  of  the  blood  elements  begins 
very  early,  one  hour  after  applying  the  mask,  it  will  be 
interesting  to  watch  whether  this  obstructed  inspiration 
might  not  be  used  to  advantage  in  surgical  patients, 
especially  after  abdominal  operations,  to  produce  artificial 
leucocytosis. 

9.  That   the   mask   incidentally   has   proved   of   great 


HYPEREMIC   TREATMENT    IX    MEDICINE.  181 

benefit  in  relieving  the  pulmonary  circulation  in  cases  of 
advanced  valvular  disease  of  the  heart,  as  also  in  cases  of 
obstinate  asthma  and  delayed  resolution  after  pneumonia. 

This  physical  treatment  of  pulmonary  tuberculosis 
will,  of  course,  not  do  away  with  the  well-tried  and  time- 
honored  treatment  by  means  of  tuberculin,*  pure  air, 
rest,  forced  nutrition,  proper  drugs,  etc. 

It  is  hut  another,  though  most  important  link  in  the  chain 
of  our  therapeutic  resources  in  the  fight  against  and  pro- 
bable ultimate  conquest  of  this  scourge  of  mankind. 

It  increases  the  natural  protecting  forces  of  the  organism, 
by  means  of  strengthening  the  normal  functions  of  the 
body. 

It  will  prove  to  be  of  especial  value  in  dispensary  prac- 
tice and  in  the  treatment  of  such  phthisical  patients  as  are 
not  endowed  with  the  riches  of  this  world  and  cannot  afford 
to  leave  their  homes  and  their  families. 

That  osteoperiostitis,  due  to  the  metastatic  invasion  of  Bone-metasta- 
sis Following 
the  typhoid  bacillus,  can  be  nicely  and  promptly  overcome  Typhoid. 

by  obstructive  hyperemia  has  been  repeatedly  seen  by 
Bier.  The  advantages  of  possibly  avoiding  operative 
work  in  these  reduced  patients  are  obvious.  Further 
reports  on  this  subject  must  be  looked  for  with  interest. 

The  acute  rheumatic  affection  of  the  sheaths  of  the  Lumbago, 
lumbar  muscles  (lumbago)  yields  very  satisfactorily 
to  hyperemic  treatment.  Cupping  has  been  employed 
for  ages,  but  the  hot-air  hyperemia  lately  applied  has 
given  better  results.  For  this  purpose  a  special  chair  has 
been  constructed,  similar  to  the  Morris  chair.  (Fig.  93.) 
The  movable  back  rest  is  provided  with  a  cut-out  of  suffi- 
cient size  to  receive  the  patient's  back,  behind  which  a 

*  The  effect  of  tuberculin  injections  in  phthisical  patients  will  prob- 
ably be  increased  by  artificial  hyperemia  of  the  lungs. 


182 


BIER  S    HYPEREMIC   TREATMENT, 


hot-air  box  is  placed,  heated  in  the  manner  previously 
described.  The  patients  highly  praise  the  comfort  afforded 
by  this  chair  no  less  than  the  rapid  improvement  of  their 
trouble. 

Sea-sickness.  Also  to  overcome  this  much-dreaded  annoyance  to  the 

seafaring  public,  hyperemia  has  been  tried  in  various  ways. 


Fig.  93. — This  figure  illustrates  the  hot-air  box  treatment  of  the 
back,  for  lumbago.  The  patient's  back,  exposed,  rests  in  the  cut-out 
of  the  chair  over  which  the  hot-air  box  is  applied.  The  latter  is  heated 
from  below.  The  apparatus  is  constructed  on  the  lines  of  a  Morris 
chair. 


The  head  hyperemia  by  means  of  the  elastic  band,  has  given 
best  results.  This  would  seem  to  furnish  evidence  in 
support  of  the  opinion  generally  held  that  anemia  of  the 
brain  caused  by  the  motion  of  the  boat  is  to  a  great  extent 
responsible  for  the  occurrence  of  the  malady.  It  is  known 
that  many  patients  feel  best  in  a  horizontal  posture,  a 


HYPEREMIC   TREATMENT    IN    MEDICINE.  183 

fact  which  further  corroborates  the  correctness  of  this 
assumption. 

Hyperemia  by  means  of  hot  compresses  to  the  head  has 
also  been  advised,  and  a  rather  comphcated  apparatus, 
heated  by  electricity,  has  been  designed  for  this  purpose. 

Naturally,  there  is  no  reason  why  other  remedies  should 
not  be  employed  in  addition. 


CHAPTER  VI. 

HYPEREMIC   TREATMENT    IN    GYNECOLOGY    AND 
OBSTETRICS. 


Chronic  Active  hyperemia  with  the  help  of  hot  air  has  been 

metritis.  extensively  used  in  the  treatment  of  pelvic  exudates  in 

cases    of    chronic    para-    and    peri-metritis.     Here,    too, 

special  boxes,  arranged  for  the  treatment  of  patients  in 

the  recumbent  posture,  have  been  built.     The  technique 

is  the  same  as  elsewhere.     The  necessary  heat  is  provided 

"by  a  gas-jet  connected  with  a  chimney,  or  by  an  electric 

stove,  or  by  electric  lamps  attached  within  the  box.     The 

latter  is  similar  in  shape  to  the  one  used  for  the  treatment 

■    of  both  hips.     (See  Fig.  61.) 

Suction  Cups  in      Of  late  the  suction  cup  has  also  been  introduced  in  gyne- 

Therapv°^*^       cologic  therapy.     It  is  indicated  in  some  diseases  of  the 

uterus  and  its  immediate  neighborhood.     It  has  the  shape 

of    the    well-known    old-fashioned    glass- tube    speculum, 

but  is  made  of  plain  glass.     (Fig.  94.)     Its  one  extremity 

is  straight,  not  oblique,  and  slightly  funnel  shaped  for 

receiving  the  cervix.     The  other  end  is  closed;   near  this, 

a  small  tube  is  attached  which  connects  with  the  rubber 

tube  carrying  the  three-way  cock.     The  air  is  rarefied  by 

way  of  the  suction-pump. 

Two  other  styles  of  cups  are  in  the  market;  one  with 
a  straight  cylindric  end  (Fig.  95) ;  the  other,  which  is 
similar  to  the  old-fashioned  vaginal  speculum,  has  a 
graded  glass  bulb,  showing  the  amount  of  mucus  or  other 
uterine  discharge  brought  out  by  the  suction.  The  degree 
of  hyperemia  can  be  watched  through  the  glass.  (Fig.  96.) 
Technique.  As  regards  the  technique,  the  same  general  rules,  given 

for  the  use  of  the  suction  cup,  apply  here.     After  five 

184 


HYrEREMIA    IX    GYNECOLOGY    AND    OBSTETRICS. 


185 


minutes'  suction,  two  to  three  minutes'  rest,  in  order  to 
give  the  artificially  accumulated  blood  a  chance  to  become 
distributed.  Duration,  in  all  about  one-half  hour  per  day. 
Moderation  cannot  he  too  strongly  emphasized.  The  applica- 
tion  must  be  painless. 


Fig.  94 


Fig.  96. 


Fig.  9.5 


Figs.  94  to  96. — Suction  glasses  for  the  cervix  uteri. 


Gynecologists  have  formulated  the  following  indications  Indications, 
for  hyperemic  suction  treatment : 

In  puerperal  infection,   to  avoid  general  pyemia;    for 
the  betterment  of  amenorrhea;   for  the  artificial  interrup- 


186 


BIER  S   HYPEREMIC  TREATMENT 


Parametritis 
Posterior. 


tion  of  pregnancy;  to  improve  the  drainage  of  mucous 
and  purulent  uterine  discharge;  in  chronic  metritis,  with 
the  exception  of  those  cases  that  are  comphcated  with  a 
suppurative  process  of  the  adnexa;  in  ulcerations  of  the 
cervix. 

It  is  impossible,  at  this  date,  to  properly  estimate  the 
benefit  to  be  derived  from  hyperemic  treatment  in  these 
cases.  Further  experience  and  improved  technique  are 
needed. 

Recently  favorable  results  have  been  reported  from 
the  use  of  a  modified  technique  of  the  treatment  in  cases 
of  chronic  changes  in  the  uterus  and  pelvic  cellular  tissue, 
described  as  parametritis  posterior  or  parametritis  chronica 
atrophicans.  Here  a  high  degree  of  suction  is  employed 
w^ith  the  view  of  stretching  and  softening  the  uterine  adhe- 
sive bands.  The  cervix  is  aspirated  for  some  distance  into 
the  vaginal  cup  and  discharges  profusely  under  this 
negative  pressure.  The  method  has  been  called  "suction 
massage."  Only  during  the  first  sitting  slight  pains, 
similar  in  character  to  those  of  labor,  are  brought  on.  In 
the  beginning  the  treatment  is  given  daily,  for  about 
twenty  minutes,  with  the  usual  interruptions;  later  on, 
less  frequently.  Many  patients  are  reported  to  have  been 
cured  of  their  pains  and  troubles,  and,  incidentally,  the 
fluor  albus  also  is  said  to  have  disappeared. 

All  of  the  above  clinical  observations  are  of  recent  date. 
They  have  been  mentioned  here  merely  for  the  sake  of 
completeness.  But  the  outlook  of  bringing  permanent 
relief  by  means  of  suction  hyperemia  and  suction  massage, 
to  these  sufferers  from  chronic  formerly  rather  intractable 
diseases,  seems  bright. 
Dysmenorrhea.  Attempts  have  been  made  to  relieve  dysmenorrheic 
troubles  by  applying  the  large  suction  glasses  of  Klapp  to 
the  breasts.  (Figs.  23  and  24.)  Application,  once  to  twice 
fifteen  minutes  per  day.  A  distinct  sensation  of  distention 
of  the  breasts  must  be  produced,  but  no  pain.     The  treat- 


IN    GYNECOLOGY    AND    OBSTETRICS,  187 

ment  is  begun  a  few  days  before  the  expected  menstruation 
and  continued  until  it  ceases.  Effect,  hyperemia  of  the 
breasts  continues  for  hours  and  days;  the  advent  of  men- 
struation is  retarded;  the  formerly  prolonged  flow  lasts 
a  shorter  period  and  is  connected  with  less  pain. 

The  explanation  of  this  phenomenon  is  to  be  found  in 
the  close  connection  between  breast  and  uterus. 

With  reference  to  the  field  of  obstetrics,  it  is  worthy  of  Puerperal 

,       .,     .  1  »  ,.  1    .       Inflammation 

note  that  several  cases  oi  nonsuppurative,  puerperal  m-  of  the  Knee. 
flammation  of  the  knee,  which  so  often  lead  to  permanent 
stiffness,  have  been  cured  by  Bier  by  means  of  obstructive 
hyperemia,  w^ith  very  satisfactory  function  of  the  joint. 

The  treatment  of  puerperal  mastitis  with  suction  cups  Puerperal  Mas- 
has  been  extensively  discussed  above  (pages  96-100). 

It  was  suggested,  and  has  been  found  of  benefit  in  prac-  Deficient  Lac- 
tice,  to  apply  the  large  suction  glasses  as  used  in  cases  of  ^  '°°* 
mastitis  of  the  female  breast,  to  increase  the  production 
of  milk  in  nursing  mothers,  and  to  start  anew  the  flow  of 
milk  that  had  stopped. 


Acute 
Gonorrhea. 


CHAPTER  VII. 

HYPEREMIC  TREATMENT  IN  GENITO-URINARY 
SURGERY. 

With  regard  to  the  value  of  the  hyperemic  treatment 
in  genito-urinary  surgery,  the  different  authors  are  widely 
at  variance.  A  great  deal  of  work  and  careful  observation 
by  many  clinicians  are  still  required  to  clear  up  the  atmos- 
phere. 

In  the  male  sex  the  effect  of  obstructive  hyperemia 
•in  an  acute  attack  of  this  principal  representative  among 


Fig.  97. — Suction  glass  for  the  pars  pendula  penis  in  case  of  gonorrhea. 


the  infections  of  the  genital  system,  becomes  somewhat 
problematical,  owing  to  the  difficulty  of  estimating  clini- 
cally the  line  of  advance  of  the  gonococcus.  But  little 
work  along  these  lines  has  been  reported  in  the  literature. 
There  is  on  the  market  a  special  suction  glass  for  this 
purpose,  similar  to  the  one  used  for  the  fingers  with  parony- 
chic  infection,  large  enough  to  receive  the  pars  pendula 
penis.     (Fig.  97.)     Perhaps  a  larger  glass  that  would  hold 

188 


HYPEREMIA    IN    GENITO-URINARY    SURGERY.  189 

in  addition  the  scrotum  plus  testicles,  and  would,  there- 
fore, influence  the  urethral  canal  down  to  the  cut-off  muscle, 
would  offer  greater  advantages.  Surely,  the  other  well- 
known  methods  of  combating  gonococcous  invasion  can- 
not be  set  aside. 

If  prostate  and  seminal  vesicles  have  become  involved,  '^^"*®^^°^°!.". 
.  .  '  rheal  Prostatitis 

the  difficulties  with  regard  to  the  use  of  hyperemia  increase,  and  Seminal 
A  metal  tube  with  a  window  on  the  concave  side,  con-    ^^^^^  ^  ^^' 
structed   after   the   model   of   the   so-called  rectal   sound 
(Fig.  98),  has  been  proposed  for  the  induction  of  hyperemia 
in  these  organs;    but  the  same  needs  improvement.     The 
window^  is  not  large  enough,  and  its  edges  are  too  sharp. 


Fig.  98. — Suction  apparatus  for  the  prostate.  The  same  can  be 
used  for  the  hyperemic  treatment  of  tuberculous  ulcerations  at  the 
neck  and  in  the  fundus  of  the  bladder.  It  is  introduced  into  the  rectum 
or  into  the  vagina;  especially  for  the  latter  purpose,  there  is  ample 
room  for  improvement. 

A   priori,   a   favorable   influence   upon   acute   gonorrheic 

prostatitis    or    spermatocystitis    may    with    propriety    be 

expected.     But  as  stated   above,   no   experience   of   real 

practical  value  has  been  reported  thus  far. 

While  some  authors  claim  to  have  seen  but  little  benefit  4^"*®  J'?°.°/" 

rheal  Epididy- 
in  this  class  of  cases  from  the  use  of  obstructive  hyperemia  mitis. 

i.  e.,  with  the  tube  around  the  base  of  the  scrotum,  others 

report  excellent  results  from  this  procedure. 

Suction  glasses  into  which  the  testicles  were  aspirated 
have  also  been  tried.    (See  Fig.  88.) 

The  tube  is  tied  gently  around  the  artificially  formed 
scrotal  pedicle.     (Fig.  10.)     If  properly  applied,  prompt 


190  bier's  hyperemic  treatment 

subsidence  of  pain  has  been  noted;  in  fact,  the  rapid 
decrease  and  final  disappearance  of  the  pains  may  be 
looked  upon  as  proof  of  a  correct  technique.  Hyperemia 
is  employed  for  twenty  hours  per  day,  with  four  hours'  in- 
termission, during  which  latter  the  testicles  are  kept  in  an 
elevated  position. 

As  soon  as  the  pains  have  ceased  and  the  intense  tender- 
ness has  been  overcome,  the  time  of  wearing  the  tube  is 
greatly  shortened.  Brief  periods  of  obstructive  hyperemia, 
twice  a  day,  plus  hot-air  douche,  are  ordered  instead.  The 
latter  is  applied  directly  against  the  scrotum,  the  patient 
being  made  to  firmly  press  the  testicle  against  the  skin. 
In  this  way  a  depth  effect  is  produced  and  the  infiltration 
is  lessened  and  slowly  absorbed.  This,  if  done  in  the  acute 
stage,  also  tends  to  avert  sterility,  the  frequent  sequela 
of  gonorrheal  epididymitis.  It  is  not  absolutely  neces- 
sary that  these  patients  stay  in  bed. 

Further  careful  studies  ought  to  be  made  to  determine 
the  effect  and  value  of  the  various  forms  of  hyperemia  in 
these  cases.     Such  investigations  should  be  carried  on  in 
clinics  or  wards,  set  aside  for  the  treatment  of  venereal 
diseases,  by  men  who  have  sufficient  interest  in  the  method 
to  be  willing  to  give  the  patience  and  time  necessary  for  a 
faithful  trial. 
Acute  Ascend-       In  the  female  sex  early  suction  massage  of  the  uterus 
in  the  Female,    by  means  of  the  special  glass  described  above,  after  thorough 
irrigation  and  disinfection  of  the  vagina,  may  occasion- 
ally prevent  the  spread  of  the  process  to  tubes  and  ovaries 
and  thus  exert  a  favorable  influence  from  a  prophylactic 
standpoint. 
Subacute  Gon-       In  the  subacute  stage  of  gonorrheal  urethritis  in  the 
ti"  Pn)statitis""  rn^le,  as  well  as  in  subacute  inflammations  of  the  prostate, 

Vesiculitis  and    seminal  vesicles  and  epididymis,  artificial  hyperemia  wiU 
Epididymitis.  r  ^         f>  -iit-i 

most  probably  be  oi  benefit,  particularly  if  it  be  combined 

with  hot  moist  applications. 


IX    GEXITO-URIXARY    SURGERY.  191 

Great  absorbing  power  being  one  of  the  chief  character-  Cavernitis   and 
istics  of  hyperemia,  it  is  easy  to  understand  that  it  will  flammatorv   "" 
prove  of  value  in  causing  to  go  down  infiltrations  in  the  Deposits;  Bar- 
corpora  cavernosa,  due  to  either  purely  gonorrheal  or  mixed  guinal  Adenitis, 
infection,  peri-urethral  deposits,  bartholinitis  and  inguinal 
adenitis.     No  doubt,  more  definite  data  will  be  brought 
out    in    the    near    future.     (With    reference    to    inguinal 
adenitis  see  page  91.) 

The  complicating  acute  gonorrheal  joint  affections  have  Acute  Gonor- 
rheal Joint  Af- 
been  previously  described  at  length.     Again  it  should  be  fections. 

stated  that  the  family  physician  or  specialist,  whoever  may 
first  see  the  case,  cannot  do  better  than  to  primarily  remem- 
ber Bier's  treatment.  Nowhere  else  is  its  effect  of  such 
truly  magic  character  as  here. 

That  chronic  cases  of  gonorrheal  ioint  inflammation  and  Chronic  Gonor- 
^  *"  rheal  Joint  In- 

joint  stiffness  are  still  amenable  to  great  improvement  under  flammations. 

obstructive  as  well  as  hot-air  hyperemia  has  been  demon- 
strated and  mentioned  above. 

Of  hyperemia  in  venereal  ulcer  and  hard  chancre  little  Primary  Speci- 
is  known  to  elate;  in  fact,  it  seems  to  have  been  tried  to  a 
very  limited  extent  only  in  specific  infection.  There  has 
been  no  benefit  from  the  treatment  in  ulcus  molle  in  the 
acute  stage,  while  callous  ulcers  have  shown  improve- 
ment. It  certainly  seems  that  it  might  be  worth  while 
to  ascertain  how  the  spirocha?ta  pallida  at  the  place  of 
the  primary  lesion  will  react,  whether  or  not  hj^peremic 
treatment  alone  or  in  combination  witli  other  remedies 
w411  prevent  generalization  of  the  infection. 

Among  the  chronic  infections  tuberculosis  of  the  prostate  Tuberculosis  of 
and  testicles,  inclusive  of  seminal  vesicles,  takes  first  rank.     ^     ^'^^  *  ^' 

So  far  tuberculosis  of  the  prostate  is  an  incurable  dis- 
ease. The  partial  or  total  extirpation  of  the  gland  in  these 
cases  has  given  but  poor  results.     Under  general  hygienic 


192  bier's  hyperemic  treatment 

regime  and  topic  applications,  the  disease  has  behaved 
rather  refractorily.  It  is  still  the  crux  of  genito-urinary  sur- 
gery, and  usually  the  beginning  of  a  most  tormenting  mal- 
ady. Frequently  gonorrheal  inflammation  paves  the  way 
for  the  invasion  of  the  tubercle  bacillus  in  patients  so  dis- 
posed. 

It  is  to  be  hoped  that  hyperemia  treatment  is  destined  to 
bring  relief  in  this  drought  of  efficient  methods.  But  if  any- 
where, then  here  patience  and  preseverance  on  the  part  of  the 
patient  as  well  as  the  attending  physician  are  required. 

However,  in  the  face  of  his  intense  suffering,  the  patient 
will  probably  be  more  than  willing  to  give  the  treatment  a 
trial,  especially  if  he  be  told  of  the  splendid  results  obtained 
with  the  method  in  surgical  tuberculosis  in  other  localities. 
"It  is  up  to  the  specialist  now  to  improve  the  armamentar- 
ium in  order  to  render  feasible  the  application  of  the  treat- 
ment also  in  this  class  of  cases. 
Se'seminaf  °^      Incidentally  with  the  prostate,  the  seminal  vesicles,  if 
Vesicles.  affected,  could  be  subjected  to  hyperemia  by  way  of  the 

rectum. 

The  attempt  to  work  through  the  posterior  urethra  with 
suction  glasses  of  special  construction,  while  not  very  plau- 
sible, might  yet  be  worthy  of  consideration,  in  connection 
with  the  attack  through  the  rectum. 

Tuberculosis  of      Tuberculosis  of  the  testicles  has  already  been  discussed 
the  Testicles.  "^ 

in  a  previous  chapter.     (See  pages  153-157.) 

The  refractory  behavior  of  syphilitic  affections  in  general 

under  artificial  hyperemia  has  there  also  been  mentioned. 

Descending  The  surgery  of  the  kidneys,  ureter,  and  bladder  will  prob- 

Unnary  Tuber- 

culosis.  ably  derive  less  benefit  from  artificial  hyperemia  than  is  ex- 

pected in  the  genital  sphere.  Radical  operative  procedure 
will,  no  doubt,  continue  to  wield  the  scepter  here,  although 
it  would  seem,  in  view  of  the  excellent  results  obtained 
with  hyperemia  in  tuberculous  disease  in  other  localities, 


IX    GEXITO-URIXARY    SURGERY.  193 

that  a  trial  of  the  same  in  inoperable  tuberculous  lesions  of 
the  urinary  system  should  not  be  omitted.  Of  course,  we 
shall  continue  to  promptly  extirpate  one  kidney,  if  found  to 
be  the  seat  of  a  descending  trouble  principally  in  the  early 
stage.  But  in  those  desperate  cases,  in  which  the  remain- 
ing kidney,  too,  has  become  affected,  and  ulcerative 
catarrh  of  the  trigonum  of  the  bladder  has  set  in,  giving  rise 
to  such  almost  intolerable  suffering,  it  certainly  seems 
that  artificial  hyperemia  with  suitable  glasses  should  be 
given  a  very  careful  trial,  especially  in  the  female.  A  cup 
with  a  properly  shaped  window  applied  to  the  anterior  wall 
of  the  vagina  (Fig.  98),  'might  exert  a  beneficial  influence 
upon  the  base  of  a  tuberculous  bladder  and  help,  in 
conjunction  with  topical  applications,  in  bringing  to 
cicatrization  these  obstinate  ulcerations.  Surely,  every 
addition  to  our  therapeutic  resources  in  this  sad  and 
trying  chapter  of  urinary  surgery  should  be  welcome.* 

Many  of  these  remarks,  hinting  at  possible  future  uses  of 
the  method,  are  made  merely  for  the  purpose  of  starting 
clinical  research  in  a  direction  where  useful  methods  are  so 
sorely  needed.  May  some  of  these  suggestions  soon  be 
taken  up  and  successfully  carried  out  by  the  numerous  ad- 
mirers of  Bier's  fascinating  work. 

*With  reference  to  hyperemic  treatment  of  a  tuberculous  affection 
of  the  remaining  kidney,  after  nephrectomy  for  a  descending  tubercu- 
lous process,  it-'might  be  suggested  to  perform  nephropexy  after  ex- 
tensive decapsulation,  or  partial  resection  of  the  kidney  according  to 
findings,  under  spinal  anesthesia,  and  then  apply  regularly  obstructive 
hyperemia  by  means  of  large  suction  glasses  in  the  respective  lumbar 
region  for  many  months.  The  well-known  depth-effect  of  this  method 
might  prove  of  benefit,  all  the  more,  if  the  patient  could  be  placed 
under  a  general  hygienic  regime. 


13 


CHAPTER  VIII. 
HYPEREMIC  TREATMENT  IN  OTOLOGY. 
Acute  Otitis  A  new  and  promising  field  of  usefulness  has  been  opened 

Media  with 

Mastoiditis ;  Ex-  up  to  obstructive  head  hyperemia  (extensively  explained 
acerbation  of  a  «o^-.\-/  r  •    n     ~  •  r 

Chronic  Middle-  above,  on  pp.  38-41)  m  the  treatment  of  mfiammations  of 

tion.  the  middle  ear  and  the  complicating  mastoiditis.    Unassail- 

able proof  has  been  rendered,  principally  at  Bier's  own  clinic, 
under  the  supervision  and  cooperation  of  a  well-known  ear 
specialist,  that  a  large  percentage  of  cases  of  acute  otitis 
media  purulenta  with  mastoiditis,  as  well  as  of  acute  exacer- 
bation of  old  middle  ear  inflammations,  can  be  cured  with- 
out any  major  operation. 

Very  recent  cases  heal  under  obstructive  hyperemia  alone. 
If  inspection  of  the  drum  membrane  suggests  an  accumula- 
tion of  pus  in  the  middle  ear,  paracentesis  is  promptly  done, 
or  a  former  perforation  is  dilated.  With  continued  artificial 
hyperemia  the  fever  usuall}^  drops  quickly  and  the  inflam- 
matory process,  with  its  pathognomonic  pain,  tenderness, 
redness  and  swelling  over  the  mastoid,  gradually  subsides. 

Abscess  over  If,  after  the  auricle  has  been  pushed  forward  the  soft 

the  Mastoid  .... 

Process.  parts  over  the  bone  suggest  the  presence  of  pus,  an  mcision  of 

sufficient  size  is  made  to  allow  of  thorough  evacuation  of  the 
pus.  This  can  be  done  under  local  anesthesia.  Here, 
again,  no  drainage  is  employed;  only  a  loose  aseptic  gauze 
dressing  is  placed  over  the  wound.  The  hyperemia  treat- 
ment is  continued  and,  in  many  cases,  will  suffice  to  effect 
healing. 

194 


HYPEREMIC  TREATMENT  IX  OTOLOGY.        195 

Acute  inflammatory  processes  of  the  temporal  bone  yield 
to  obstructive  hyperemia  like  acute  osteomyelitis  of  the 
extremities.  If  the  treatment  be  applied  in  the  begin- 
ning, the  entire  process  may  be  rendered  abortive.  If  an 
abscess  has  formed,  this  must  be  incised;  the  subsequent 
occurrence  of  necrosis  can  thus  be  prevented. 

The  elastic  band  around  the  neck  is  worn  regularly  for  Technique, 
ten  to  eleven  hours  twice  per  day,  or  uninterruptedly  for 
twenty-two  hours  with  two  hours'  intermission.  A  correct 
technique  is  all-essential.  The  head  being  abundantly 
provided  with  blood,  but  gentle  tension  of  the  neck-band  is 
sufhcient  to  produce  a  marked  and  satisfactory  hyperemia. 

In  acute  cases  the  resulting  edema  of  the  face  may  be 
very  pronounced.  This,  however,  should  not  deter  the  at- 
tending surgeon  from  continuing  the  treatment,  as  it  is  just 
these  cases  that  promise  best  results. 

After  improvement  becomes  apparent — i.e.,  after  the  fever 
and  tenderness  over  the  mastoid  process  have  disappeared — 
the  time  of  application  of  the  band  is  gradually  shortened 
by  two  hours  each  day,  until  a  cure  has  been  accomplished. 

This  gradual  diminution  of  the  duration  of  the  hyperemia 
acts  as  a  preventive  against  a  recurrence  of  the  symptoms. 
Hyperemic  treatment  must  never  be  stopped  abruptly.  There 
must  be  no  antiseptic  irrigation  or  insufflation  by  way  of  the 
auditory  canal.  The  latter  is  gently  wiped  out  with  a  swab 
of  moist  cotton  twice  per  day.  It  is  packed  loosely  with 
sterile  cotton  or  gauze,  which  has  to  be  changed  frequently, 
according  to  the  amount  of  secretion. 

The  patient  may  be  out  of  bed  as  soon  as  he  has  become 
afebrile. 

In  some  cases  improvement  is  rather  slow.     This  should 


196  bier's  hyperemic  treatment. 

not,  however,  make  the  surgeon  feel  that  he  has  to  operate. 
We  know  of  one  case  of  acute  suppurative  otitis  media  and 
mastoiditis  which  showed  very  httle  improvement  at  the 
end  of  four  to  five  weeks,  and  yet  was  finally  cured  under  per- 
sistent hyperemic  treatment.  Of  course,  it  requires  faith 
in  the  method,  thorough  mastery  of  its  technique,  and  care- 
ful supervision  of  the  patient  to  continue  the  hyperemia  in 
the  face  of  such  slow  convalescence.  However,  the  func- 
tional result  with  regard  to  the  degree  of  hearing  is  usually 
brilliant. 

There  is  no  entire  unanimity  of  opinion  among  otologists 
as  to  when  trephining  of  the  mastoid  process  is  indicated. 
Even  the  most  experienced  men  have  at  times  been  surprised 
not  to  find  pus  where  is  was  surely  expected.  Any  method 
which  helps  to  solve  the  difficulty  of  establishing  the  correct 
indication  for  operation  must,  therefore,  be  welcome. 

On  basis  of  the  experience  so  far  had  with  hyperemic 
treatment  in  this  class  of  cases,  it  can  be  definit-ely  stated 
that  many  an  operation  of  trephining  will  become  unneces- 
sary, if  hyperemia  be  promptly  started  and  correctly  carried 
out  in  the  event  of  a  threatening  or  beginning  mastoid  com- 
plication. 

Intracranial  Of  course,  the  surgeon  must  be  on  his  guard  lest  compli- 

Complications.         ,.  .  c^.  i  i  i  •,  •  i    i       •       i 

cations  arise,     bmus-phlebitis  and   bram-abscess  require 

prompt  operation,  while  a  threatening  meningitis  may  prob- 
ably be  prevented  or,  if  already  present,  beneficially  influ- 
enced by  obstructive  hyperemia.  There  is  no  need  of  bar- 
ring other  modes  of  treatment — e.  g.,  lumbar  puncture — 
slight  though  the  benefit  derived  from  this  has  been. 

Chronic  Otitis        In  chronic  cases  of  otitis  media  or  those  of  cholesteatoma, 
Media;    Chole-  .  ...  i       i  i  i        7- 

steatoma.  artificial  hyperemia  without  operation  should  be  discour- 


HYPEREMIC  TREATMENT  IX  OTOLOGY.        197 

aged.  Most  of  these  are  strictly  surgical  cases,  although  in 
the  slow  healing  of  the  bone  cavities  following  extensive 
mastoid  operations,  the  neck-band  will  often  prove  of 
great  help  in  hastening  convalescence. 

It  must  be  tempting  to  experiment  with  head  hyperemia  Diseases  of  the 
in  many  of  the  intractable  diseases  of  the  labyrinth  of  the    *  ^"'^ 
ear,  particularly  if  due  to  chronic  anemia. 

In  closing  this  interesting  chapter,  the  hope  is  expressed 
that  otologists  will  take  up  Bier's  treatment  and  give  it  a 
fair  test  in  suitable  cases.  Much  work  is  yet  required  in 
this  field,  and  it  must  be  approached  in  an  unprejudiced 
manner.  Surely  otologists  cannot  shut  their  eyes  or  ears 
to  what  has  already  been  accomplished  in  acute  mastoiditis 
with  hyperemia. 

Some  of  the  many  interesting  questions  that  still  await  ^™®  °^  *^® 

solution  in  connection  with  hyperemia  in  otology  are,  ac-  Questions  Still 

Awaiting 
cording  to  Bier,  the  following :  Solution. 

1.  Do  acute  ear  inflammations  due  to  different  causes  re- 
act differently  to  artificial  hyperemia? 

2.  Can  chronic  cases  of  otitis  media  when  there  are  no 
sequestra  and  the  bone  cavities  are  filled  with  granulations 
be  benefited  by  hyperemia  alone? 

3.  Is  it  advisable  to  use  hyperemia  in  the  presence  of 
sinus  thrombosis  and  brain  abscess? 

4.  Should  we  confine  ourselves  to  the  use  of  the  elastic 
neck  band  after  an  abscess  over  the  mastoid  has  been 
opened,  or  may  we  have  recourse  to  the  suction  glass  also? 

It  is  clear  that  the  tests  necessary  to  render  possible  cor- 
rect answers  to  above  questions  are  best  made  in  well-con- 
ducted hospitals  and  clinics.     In  private  practice  they  are 


198  bier's  hyperemic  treatment. 

feasible  only  if  a  nurse,  who  has  thoroughly  grasped  the 
principle  of  hyperemic  treatment,  can  be  in  constant  attend- 
ance upon  the  patient  under  the  direction  of  the  specialist 
or  his  assistants. 

In  all  the  ear  cases  observed  at  Bier's  clinic  the  treat- 
ment was  administered  by  the  same  assistant. 


CHAPTER  IX. 
HYPEREMIC  TREATMENT  IN  OPHTHALMOLOGY. 

The  therapy  for  the  treatment  of  diseases  of  the  eye  also 
seems  to  have  been  enriched  by  Bier's  treatment.  Obstruc- 
tive hyperemia,  by  means  of  the  neck-band  as  well  as  with 
the  help  of  suction  glasses,  is  here  of  value.  In  view  of  the 
delicate  construction  of  the  eye,  local  treatment  naturally 
demands  extreme  carefulness  on  the  part  of  the  operator. 

The  question  whether  gentle  head-hyperemia  will  influ- 
ence the  interior  of  the  eye  also,  has  not  been  definitely 
settled  as  yet.  Still,  sufficient  proof  seems  to  have  been  ren- 
dered for  the  assertion  that  the  various  membranes  of  the 
bulbus,  inclusive  of  disc  and  retina,  participate  in  the  effects 
of  a  moderate  hyperemia,  such  as  results  from  the  appli- 
cation of  the  neck-band. 

It  seems  to  have  been  proven  by  the  fact  that  marked  omfc  A^ro^hv 
improvement  from  this  method  has  recently  been  seen  in 
a  few  cases  of  progressive  optic  atrophy  with  pronounced 
anemia  of  the  optic  nerve,  a  result  which,  a  'priori,  seems 
but  natural  and  altogether  plausible,  provided  the  trouble 
has  not  advanced  too  far. 

The  inflamed  eye  answers  better  to  obstructive  hyper- 
emia than  the  one  in  which  the  circulation  is  normal,  same 
as  this  is  seen,  e.  g.,  in  the  leg  which  harbors  an  inflamed 
focus. 

The  technique  is  the  same  as  in  the  case  of  other  inflam-  Technique. 

mations  of  the  head  and  cranial  cavity;  the  elastic  band 

remains  in  place  for  eleven  hours  twice  a  day. 

Brilliant  has  been  the  success  of  the  treatment  in  acute  Acute    Dacryo- 

cystitis, 
dacryocystitis  with  abscess  formation. 

199 


200 


BIER  S    HYPEREMIC   TREATMENT. 


Parenchyma- 
tous Keratitis. 


Sympathetic 
Ophthaknia. 


Inflammatory 
Diseases  of  the 
Eyelids  and 
Conjimctiva. 


Sty. 


Also  other  acute  inflammations  of  the  eye — e.g.,  parenchy- 
matous keratitis — have  been  favorably  influenced  by  hyper- 
emia. 

It  is  to  be  expected  that  cases  of  sympathetic  oph- 
thalmia will  yield  to  obstructive  hyperemia,  particularly  if 
the  latter  be  applied  at  an  early  stage  of  the  trouble. 

For  inflammatory  diseases  of  the  eyelids  and  conjunctiva 
suction  hyperemia  is  best  suited.  The  size  of  the  cup 
must  be  adapted  to  the  specific  purpose  for  which  it  is  re- 
quired. The  same  is  placed  directly  over  the  diseased  spot 
as  in  cases  of  sty  (Fig.  99),  or  it  covers  the  entire  orbit. 
From  the  rubber  tube  connecting  cup  and  bulb  a  branch 


Fig.  99. — Suction  glass  for  sty. 


springs,  which,  in  turn,  connects  with  a  manometer.  For 
the  eye  this,  surely,  is  an  important  addition,  which  is  un- 
necessary for  other  parts  of  the  body.  It  has  been  found 
that  it  is  unwise  to  exert  a  negative  pressure  beyond  twenty 
to  thirty  millimeters  for  children,  and  forty  to  fifty  milli- 
meters for  adults.  The  pressure  is  easily  gaged  by  allow- 
ing the  compressed  bulb  to  slowly  expand  until  the  desired 
degree  of  suction  is  obtained,  as  indicated  by  the  manometer, 
when  an  artery  forceps  is  applied  to  the  tube,  thus  checking 
further  suction.  A  too  high  degree  of  suction  will  cause 
localized  punctuated  extravasation  of  blood  and  a  bluish 
edema,  which  will  last  for  days. 


hypere:mic  treatment  ix  ophthalmology.      201 

If  no  manometer  is  at  hand,  the  patients'  own  feeUng 
here,  too,  must  be  the  guide  for  the  correct  degree  of  nega- 
tive pressure.  "WTiile  they  should  experience  a  sensation 
of  suction  on  the  hd,  they  must  not  feel  any  pain.  There 
may  be  some  watering  of  the  eye,  which,  however,  ceases 
with  the  interruption  of  the  treatment.  The  function  of 
the  eye  remains  unimpaired.  Not  in  a  single  instance  has 
harm  been  done  by  artificial  hyperemia. 

The  treatment  is  usually  given  two  to  three  times  a 
day,  for  fifteen  to  thirty  minutes,  without  intermission. 
It  does  not  necessitate  any  interruption  in  the  patient's 
regular  work,  except  for  the  actual  time  of  application. 

In  the  event  of  abscess  formation  the  pus  must  be  evacu- 
ated, same  as  this  has  to  be  done  in  any  other  part  of  the 
body.  A  small  incision  will  suffice.  Curettement  of  the 
cavity  may  be  added  at  once.  If  suction  is  then  promptly 
resorted  to,  this  will  often  materially  hasten  convalescence. 

The  hyperemic  treatment  of  the  eye  should  never  be 
given  into  the  hands  of  the  patient  or  nurse,  but  should 
be  carried  out  by  the  specialist  himself. 

It  is  by  no  means  intended  that  hyperemia  should  super- 
sede the  other  useful  methods  in  vogue  in  those  cases  of 
local  inflammation.  On  the  contrar}^,  there  are  conditions 
in  which  its  application  may  be  contraindicated  or  not 
feasible,  and  here,  of  course,  the  time-honored  treatment 
by  incision,  curettement  and  moist  heat  must  be  resorted  to. 
But  it  certainly  is  worth  knowing  that  this  new  therapeutic 
agent  is  also  of  use  in  ophthalmology,  and  that  much 
can  be  accomplished  by  it  either  alone  or  in  conjunction 
with  other  methods,  in  simple  as  well  as  in  the  more 
serious  cases,  as  also  in  those  that  refuse  to  yield  to  any 
of  the  procedures  hitherto  employed. 

Artificial  hyperemia,  therefore,  seems  entitled  to  the 
most  careful  consideration  on  the  part  of  ophthalmologists. 


CHAPTER  X. 


HYPEREMIC  TREATMENT  IN  RHINOLOGY,  PHAR- 
YNGOLOGY,  AND  LARYNGOLOGY. 

Acute  Coryza.  Among  the  diseases  of  the  nose,  acute  coryza  holds  first 
place.  It  can  often  be  checked  within  twenty-four  hours 
under  obstructive  hyperemia  by  means  of  the  head-band, 
if  the  latter  be  applied  as  soon  as  the  "severe  cold"  has 
made  its  appearance.  The  band  should  remain  in  place 
for  twenty-two  hours  per  day,  or  twice  eleven.  Of  course, 
not  every  case  can  be  overcome  in  this  way,  but  there  is 
no  one  method  in  medicine  that  can  cure  every  case. 
Results  are  naturally  less  satisfactory  if  the  cold  is  but  a 
part  of  a  general  infection  (influenza).  Other  remedies 
may  be  employed  besides  the  hyperemic  treatment. 

The  same  beneficial  effect  may  be  observed  in  the  com- 
plicating acute  affections  of  the  frontal  sinus  and  the 
antrum  Highmori.  There  are  many  patients  who  regu- 
larly suffer  from  acute  catarrhal  inflammation  of  these 
cavities  in  connection  with  a  severe  cold.  A  sufficient 
number  of  cases  are  on  record  in  which  the  application 
of  the  elastic  neck-band,  immediately  after  the  onset  of 
the  first  symptoms,  has  prevented  the  further  develop- 
ment of  this  most  annoying  and  often  obstinate  com- 
plication, to  warrant  us  in  recommending  this  head  hyper- 
emia as  a  highly  efficient  prophylactic  measure  in  these 
cases. 

202 


Acute  Frontal 
and  Maxillary 
Sinusitis. 


IX  RHIXOLOGY,  PHARYXGOLOGY,  AXD  LARYXGOLOGY.    203 

Obstructive  hyperemia  by  means  of  the  suction  glass  Chronic      Dis- 
apphed  through  the  nostrils  (Fig.  100)  has  been  extensively  ^^^^  a^nd^lfs 
tried  for  diagnostic  purposes  as  well  as  for  the  treatment  Accessory  Sinu- 

S6S* 

of  suppurative  affections  of  the  accessory  sinuses,  includ- 
ing ozena.  However,  specialists  are  still  greatly  at  variance 
as  regards  its  value  in  these  afTections. 

Good  results  have  been  obtained  by  both  suction  and  Dry  Catarrh  of 
constriction  in  atrophic  processes  of  the  mucous  membrane  Passages, 
of  the  nasopharynx. 

As  a  matter  of  course,  hyperemia  has  also  been  tried  Hay  Fever, 
in  hay  fever,  this  crux  of  rhinologists,  and  it  has  given 
much    relief    even    in    obstinate    cases.     It    seems   worth 
bearing  in  mind  w^hen  called  upon  to  treat  such  cases. 


Fig. 100. — Suction  apparatus  for  the  nose.  Each  of  the  glass  tips  is 
introduced  into  one  of  the  nostrils.  By  rarefying  the  air  with  the  help 
of  the  suction  pump,  pus  from  the  sinuses  communicating  with  the 
nasal  cavity  is  aspirated.  Rhinologists  are  still  greatly  at  variance 
with  reference  to  the  benefit  of  this  procedure,  also  for  diagnostic 
purposes. 

In  acute  angina  obstructive  hyperemia  with  the  neck-  Acute  Tonsil- 
band  has  brought  but  subjective  improvement;  the  use 
of  the  suction  glasses,  however,  has  proved  of  value. 
Cups  of  suitable  shape  have  been  constructed;  they  are 
worked  with  a  rubber  bulb.  Various  sizes  of  these  cups 
should  be  on  hand  (Figs.  101  to  103),  and  the  one  just  large 
enough  to  grasp  the  tonsil  first  tried.  If  it  does  not  work 
or  causes  pain,  the  next  larger  or  smaller  size  should  be 
tried,  until  one  is  found  that  produces  the  desired  vacuum. 
The  fear  that  its  presence  irritates  the  pharynx  or  induces 


204 


BIER'S    HYPEREMIC   TREATMENT 


the  act  of  swallowing  or  causes  gagging  is  unfounded,  so 
long  as  the  u\aila  and  soft  palate  are  not  touched.  The 
always  increased  amount  of  saliva  is  made  to  run  off  by 
making  the  sitting  patient  slightly  turn  his  head  forward; 
the  one  in  a  recumbent  position  is  moved  to  the  edge  of 
the  bed  and  placed  in  a  latero-abdominal  posture.  The 
cup  is  best  put  in  place  by  pressing  the  tongue  down 
with  it.     If  it  be  used  for  aspiration,  to  procure  material 

Fig.  101. 


Fig.  102. 


Fig.  103. 

Figs.  101  to  103. — Suction  glasses  for  the  tonsils.  The  three  styles 
here  shown  should  at  least  be  on  hand  when  using  hyperemic  treat- 
ment for  tonsillar  affections. 


for  bacteriologic  examination,  a  spatula  should  take  care 
of  the  tongue. 

Time  of  application,  as  usual,  i.  e.,  the  cup  remains  in 
place  for  five  minutes;  it  is  then  removed  for  two  to  three 
minutes,  this  manoeuver  being  repeated  during  half  an 
hour,  twice  or  three  times  per  day.  The  glasses  should  be 
boiled  after  each  sitting  and  the  rubber  bulb  rinsed  out 
with  lysol  or  bichlorid  solution.  Effect:  marked  and 
prompt    subjective    improvement,    as    shown    in   greatly 


IN  RHINOLOGY,  PHARYNGOLOGY,  AND  LARYNGOLOGY.    205 

diminished  pain  in  swallowing,  principally  in  acute  cases 
with  pronounced  swelling,  due  to  seropurulent  transuda- 
tion into  the  tonsillar  tissue,  and  abbreviation  of  the  course 
of  the  disease.  Strange  to  say,  the  wdiite  plugs  are  not 
aspirated,  but  come  loose  gradually  only. 

No  harm  has  ever  been  done  by  this  treatment,  even 
when  it  was  not  successful. 

Also  in  these  cases,  artificial  hyperemia  is  not  claimed 
to  be  a  substitute  for,  but  an  addition  to  existing  remedies. 

In  patients  suffering  from  unilateral  pain  of  the  throat,  Chronic 
radiating  up  to  the  ear,  and  complicated  with  joetor  ex  ore, 
suction  over  the  seemingly  healthy  tonsil  in  the  interval 
may  be  successful  in  aspirating  a  white  plug — detritus 
with  bacteria — from  the  depth  of  a  lacuna,  and  therewith 
cure  the  patient. 

It  seems  that  large  but  fiat  tonsils  that  cannot  be  grasped  Hypertrophic 
with    the    tonsillotome   yield   to    the   prolonged,    faithful 
application  of  the  cup ;  a  procedure  which,  in  certain  cases, 
competes  favorably  with  the  galvanocautery. 

It  is  to  be  expected  that  early  cases  of  laryngeal  tubercu-  Tuberculosis  of 

the  Larynx, 
losis,  the  representative  of  chronic  infectious  inflamma- 
tion of  the  larynx,  will  prove  amenable   to   obstructive 
hyperemia  with  the  elastic  neck-band,  applied  below  the 
level  of  the  larynx. 

The  use  of  Kuhn's  suction  mask  has  also  shown  positive 
results  in  this  trouble. 


CHAPTER  XI. 


HYPEREMIC  TREATMENT   IN  NEUROLOGY, 
INCLUDING  PSYCHIATRY. 

A  promising  field  for  hyperemic  treatment  seems  to  lie 
in  the  direction  of  nervous  and  mental  diseases.  Its  pain- 
reducing  power  being  the  most  striking  characteristic 
of  Bier's  treatment,  it  has  proven  particularly  efficacious 
in  diseases  that  are  extremely  painful,  without  showing 
any  marked  anatomic  changes;  e.  g.,  neuralgia. 

Neuralgia.  •  Here,  again,  only  arterial  hyperemia  (by  means  of  hot 

air)  is  of  benefit.  Obstructive  hyperemia  has  been  found 
of  no  value.  It  is  advisable  to  combine  the  treatment 
with  massage  in  the  following  manner:  The  affected  area 
is  irrigated,  as  it  were,  with  the  hot  air,  the  masseur  direct- 
ing the  tube  with  one  hand,  while  he  rubs  or  kneads  the 
parts  with  the  other.  This  combined  method  has  given 
excellent  results.  A  simple  apparatus,  such  as  shown  in 
Fig.  61,  which  is  heated  by  gas,  will  answer  the  purpose. 

In  hospitals  and  clinics,  an  electric  hot-air  douche  is 
preferable,  as  it  is  simpler  to  handle. 

Sciatica.  Among  the  various  forms  of  neuralgia,  sciatica  is  the  one 

that  has  proved  most  responsive  to  hot-air  treatment, 
both  by  means  of  the  douche  (Fig.  63)  and  the  box, 
although  improvement  is  but  gradual  in  this  class  of  cases, 
especially  the  chronic  type.  In  obstinate  cases  bloody 
stretching  of  the  nerve  is  indicated. 

Tic  Douloureux.      Neuralgia  of  the  fifth  nerve,  too,  often  yields  to  hot-air 
massage,  sometimes  even  in  cases  in  which  alcohol  injection 

206 


HYPEREMIA  IX  XEUROLOGY,  IXCLUDIXG  PSYCHIATRY.    207 

or  operation  seemed  indicated.  The  patient  assumes  a 
comfortable  position,  seating  himself  in  front  of  the  douche, 
and  allows  the  hot  air  to  play  on  the  painful  area.  (Fig. 
62.)  Slowly  the  hot-air  tube  is  brought  closer  and  closer 
to  the  limit  of  the  patient's  endurance;  sometimes  it 
becomes  necessary  to  produce  a  burn  of  the  first  degree 
in  order  to  relieve  the  condition,  but,  as  a  rule,  this  is  not 
necessary.  In  severe  cases,  hot-air  massage  is  preferable. 
The  pains  disappear  gradually,  never  suddenly.  Duration 
of  application:  about  one-half  hour  daily,  with  short 
intermissions.  The  exact  period  of  treatment  must  be 
determined  by  the  attending  physician. 

The  induction  of  a  mild  degree  of  head  hyperemia  by  Headache, 
means  of  the  elastic  neck-band  has  proven  an  efficient 
means  of  dealing  with  headache.  The  headaches  due  to 
anemia  have  shown  best  results,  although  those  attribu- 
table to  suppurative  and  tuberculous  meningitis  have, 
likewise,  been  greatly  alleviated. 

There  has  always  been  a  drought  of  useful  therapeutic  Diseases  of  the 

,,  .       1        ,  r  1-      1       •  Central  Nervous 

measures  m  this  chapter  ot  medical  science.  System. 

It  has  not  been  determined  as  yet  which  form  of  hyper- 
emia will  give  best  results.  Up  to  the  present,  head  hyper- 
emia with  the  elastic  band  around  the  neck  has  been 
used.  Perhaps  suction  hyperemia  applied  directly  to  the 
skull  would  also  exert  a  beneficial  influence,  in  view  of 
its  far-reaching  depth  effect. 

A  number  of  cases  of  chorea  minor  are  reported  by  Bier  chorea, 
to  have  reacted  most  favorably  to  head  hyperemia,  the 
bandage  being  worn  twenty- two  hours  per  day.  Hunt- 
ingdon's chorea  and  a  symptomatic  case  due  to  a  brain 
tubercle  have  answered  less  favorably  to  the  treatment. 
Further  experiments  would  be  desirable. 


208 


BIER  S    HYPEREMIC   TREATMENT 


Mental  Irrita- 
bility ;      Melan- 
cholia. 


Epilepsy.  In  epilepsy  hyperemic  treatment  has  brought  temporary 

improvement  in  decreasing  the  frequency  of  the  attacks 
and  the  headaches.  Further  tests  in  homes  for  epileptics 
would  be  of  value  in  determining  the  usefulness  of  the 
method  in  these  cases,  as  far  as  they  are  not  amenable  to 
operative  treatment. 

Hyperemia  by  means  of  the  neck-band  has  been  tried 
with  some  success  in  this  class  of  cases.  Of  course  it  is 
not  to  be  expected  that  any  cures  will  be  effected;  still, 
the  treatment  represents  a  further  addition  to  the  thera- 
peutic resources  of  the  specialist  that  has  proven  of  particu- 
lar value  in  relieving  the  headaches. 

No  beneficial  effect  has  thus  far  been  noted  from  the 
treatment  in  maniacs  and  depressed  conditions  of  the 
mind. 

It  is  to  be  hoped  that  physicians  in  charge  of  asylums 
for  patients  thus  afflicted  will  take  up  the  subject  and  help 
draw  definite  lines  as  to  the  usefulness  of  artificial  hyperemia 
in  mental  disorders. 
Menin-  Since  meningeal  inflammations  of  the  brain  can  be 
treated  to  advantage  by  means  of  obstructive  hyperemia, 
as  has  been  stated  above,  it  is  but  logical  to  expect  that 
suction  hyperemia  will  exert  the  same  beneficial  influence 
upon  the  meninges  of  the  cord.  It  has  been  noted  again 
and  again  that  this  form  of  hyperemia  will  reduce  the 
pain, — for  instance,  in  Pott's  disease, — thus  proving  that 
it  reaches  the  body  of  the  vertebrae.  It  is  to  be  assumed 
that  the  cord  would  share  with  the  vertebrae  in  the  benefits 
derived  from  the  increased  blood  supply.* 


Spinal 
gitis. 


*  With  the  intention  of  drawing  blood  from  the  depth  to  the  surface, 
issues  and  the  active  cautery  have  been  used  alongside  the  spine,  as 
long  as  medicine  has  existed.  It  is  interesting  to  note  that  these  remedies 
produce  a  chronic  artificial  hyperemia  in  the  deeper  tissues,  instead 
of  the  intended  anemia.  Ample  anatomic  proof  has  been  rendered  in 
corroboration  of  the  truth  of  this  statement. 


IN    NEUROLOGY,    INCLUDING    PSYCHIATRY.  209 

Acute  (epidemic)  poliomyelitis  deserves  special  mention.  Poliomyelitis. 
Bier  himself  calls  attention  to  the  probable  value  of  hyper- 
emic  treatment  here.  According  to  observations,  which 
have  not  yet  been  published,  hyperemia  promises  a  ray 
of  hope  in  this  disease,  which  leaves  both  doctor  and  patient 
at  the  mercy  of  fate. 

It  has  been  reported  that  in  cases  of  locomotar  ataxia  Locomotor 
subjective  as  well  as  objective  improvement  has  been  ob- 
tained by  the  faithful  daily  use  of  properly  constructed 
suction  glasses.  By  means  of  a  suction  pump  worked 
by  the  foot  patients  can  themselves  apply  the  cups  over 
the  upper  and  lower  third  of  the  spine;  they  can,  of 
course,  not  reach  the  middle  third.  Neurologists  will  do 
well  to  give  this  class  of  cases  the  benefit  of  a  thorough 
trial  with  artificial  hyperemia. 

Before  closing  the  chapter  on  diseases  of  the  nervous  Lumbar  Punc- 
system.  Bier's  belief  as  to  the  true  cause  for  the  improve- 
ment, usually  noted  after  lumbar  puncture,  for  instance 
in  meningitis,  should  find  a  place.  He  avers  that  a  tem- 
porary hyperemia  of  the  cord,  perhaps  also  of  the  brain, 
is  produced  by  the  withdrawal  of  a  larger  amount  of  cere- 
brospinal fluid,  and  that  it  is  mainly  owing  to  this  hyper- 
emia that  the  condition  improves.  The  same  he  believes 
to  be  true  in  the  cases  of  ascites  treated  by  puncture, 
holding  that  a  hyperemia  of  the  abdominal  organs  is  created 
by  the  withdrawal  of  the  ascitic  fluid;  and,  likewise,  in 
cases  of  evacuation  of  a  pleuritic  exudate.  In  all  these 
cases,  he  claims,  the  relief  experienced  is  attributable 
not  to  the  mere  withdrawal  of  the  fluid  but  to  the  hyperemia 
resulting  therefrom. 


14 


CHAPTER  XII. 
HYPEREMIC  TREATMENT  IN  DERMATOLOGY. 

The  benefit  derived  from  hyperemia  also  in  the  treat- 
ment of  diseases  of  the  skin,  only  furnishes  additional 
proof  of  the  great  utility  of  this  new  therapeutic  agent. 

Skin  lesions,  in  which  all  the  remedies  of  the  pharma- 
copoeia had  been  tried  without  effect,  yielded  as  soon  as  the 
change  was  made  from  a  therapy  on  a  chemical  to  that  on  a 
physical  basis. 

Both  forms  of  hyperemia  find  employment  in  the  treat- 
ment of  skin  diseases.     Their  boundary-line  has  not  yet 
been  clearly  defined. 
Acute  Eczema,       Obstructive  hyperemia  by  means  of  the  bandage  as 

Acne,  Sycosis, 

Psoriasis,  well  as  the  suction  glasses,  has  been  recommended  for  acute 

Diseases  of  the  .         ,        .  .       .  .       , 

Nail.  eczema,  acne,  sycosis  vulgaris  et  parasitaria ;  active  hyper- 

emia for  psoriasis  and  mycotic  diseases  of  the  nail. 

Chronic  eczema  has  reacted  favorably  to  both  arterial 
and  venous  hyperemia. 

Case. — Male,  thirty-six;  chronic  eczema  of  scrotum; 
multiple  papillomatous  excrescences;  unbearable  itch. 
Consulted  many  specialists;  only  temporary  amelioration. 
Hyperemic  treatment  with  suction  glasses  of  special 
construction,  admitting  penis  plus  scrotum,  brought 
about  a  perfect  cure.  After  six  months  the  skin  of  the 
genitals  was  normal.  It  is  not  known  whether  the  favor- 
able condition  continued.  Yet  cases  like  this  should  stimu- 
late further  tests  in  such  and  similar  diseases. 

210 


CONCLUSION.  211 

There  seems  to  be  no  better  treatment  for  keloids  than  Keloids. 

obstructive  hyperemia. 

The  suction  glasses  have  brought  improvement  in  alopecia  Alopecia 

Areata, 
areata. 

They  should  also  be  tried  in  tuberculosis  of  the  skin  Lupus. 

(lupus),  particularly  when  occurring  in  the  face  of  females, 

before  recourse  is   had  to  the  a:-rays  or  extirpation  and 

subsequent  grafting.     The  grafts,  though  taken  from  the 

soft  skin  of  the  arm,  always  look  different  from  the  skin 

of  the  face;  besides  the  grafted  area  does  not  participate 

in  temporary  circulatory  changes;  e.  g.,  blushing.    A  number 

of  cases  of  lupus  of  the  face  permanently  cured  by  means 

of  obstructive  hyperemia  with  suction  glasses  are  on  record. 

Dermatologists  will  do  well  to  add  artificial  hyperemia  to 

their  armamentarium. 


CONCLUSION. 

The  above  pages  bring  in  brief  form  what  is  known 
about  Bier's  treatment  up  to  the  present  time. 

It  has  been  stated  above,  and  is  herewith  repeated, 
that  the  large  type  used  in  this  book  refers  to  affections 
in  which  the  method  has  been  sufficiently  tried  to  entitle 
it  to  universal  and  unqualified  recommendation,  whereas 
the  small  type  indicates  the  directions  in  which  hyperemic 
treatment  promises  good  results,  but  has  not  yet  been 
thoroughly  tested. 

The  fact  that  artificial  hyperemia  has  already  found 
use  in  such  a  variety  of  different  diseases,  seems  to  speak 
for  the  correctness  of  Bier's  prophecy  made  some  years  ago : 
''This  remedy,  used  by  nature  in  such  a  profuse  measure, 


212  bier's  hyperemic  treatment. 

to  combat  all  sorts  of  lesions,  is  destined  to  be  far  more 
extensively  employed  than  has  hitherto  been  attempted." 

Of  course,  it  must  not  be  assumed  that  now  the  millen- 
nium has  come;  that  all  that  is  necessary  to  effect  a  cure 
is  to  apply  the  elastic  bandage,  glass  cup  or  hot-air  box. 
Far  from  it.  If  the  rules  laid  down  in  this  book  are  not 
closely  followed;  if,  in  cases  of  acute  and  chronic  inflam- 
mations, a  correct  diagnosis,  even  as  to  details,  does  not 
underlie  the  treatment,  the  trouble  will  get  worse,  instead 
of  better  under  hyperemic  treatment. 

If,  on  the  other  hand,  the  physician  strictly  follows  the 
directions  given  and,  above  all,  is  mindful  of  the  fact 
that  a  gentle  hyperemia  only  is  required  to  produce  the 
desired  effect,  at  least  in  cases  of  acute  infectious  inflam- 
mation, in  other  words,  that  a  "too  much"  is  absolutely 
injurious,  he  will  soon  become  convinced  that  in  Bier's 
treatment  we  have  a  most  powerful  and  efficient  remedy, 
altogether  unlike  any  other  known  to  us  before.  He  wiU 
then  grasp  the  full  truth  of  Bier's  new  teachings  that  have 
revolutionized  all  our  former  theories  and  ideas  regarding 
the  nature  and  significance  of  inflammations,  proclaiming 
the  latter  a  salutary  process,  representing  nature's  own 
weapon  in  fighting  the  invading  foe,  a  phenomenon  that 
must  be  favored  and  encouraged,  not  combated.  The 
fact  that  artificial  hyperemia,  properly  applied,  can  prevent 
the  outbreak  of  a  threatening  inflammation,  or  the  spread 
of  a  beginning  one,  is  absolute  proof  of  this  assertion. 

It  has  been  pointed  out  that  hyperemic  treatment  has 
its  greatest  triumphs  when  applied  prophylactically. 
Regarding  this  there  is  no  dissenting  voice.  Even  those 
who  do  not  as  yet  accept  Bier's  teleologic  explanation  of 


CONCLUSION.  213 

the  purpose  of  inflammation  nor  the  conclusions  he  has 
drawn  therefrom  as  a  basis  for  treatment,  agree  as  to 
the  value  of  the  method  in  this  direction.  But  do  they 
not  thereby  silently  recognize  the  very  principle  Bier  has 
been  trying  to  establish,  namely,  that  by  merely  increasing 
the  volume  of  blood  alone — nature's  weapon — a  cure  can 
be  effected?  The  earlier  we  assist  nature  in  her  curative 
efforts  the  greater  are  the  chances  of  success. 

Like  a  red  thread  runs  through  the  convincing  and 
inspiring  writings  of  Bier,  the  many  publications  of  his 
pupils  and  followers,  as  also  through  the  text  of  this  book, 
the  urgent  appeal  for  an  early  and  correct  definition  of 
the  seat  and  character  of  the  inflammation,  and  prompt 
resort  to  artificial  hyperemia.  Only  in  this  manner  the 
greatest  amount  of  good  can  be  accomplished.  Likewise 
has  it  been  emphasized,  again  and  again,  that  whatever 
pus  may  have  formed  must  be  promptly  evacuated. 

It  stands  to  reason — as  it  has  been  pointed  out  above — 
that,  if  the  destructive  work  of  the  invading  bacteria  has 
been  allowed  to  go  on  unchecked,  if  thrombosis  of  the  smaller 
veins  within  the  focus  of  infection  or  even  necrosis  has 
set  in,  nothing  in  the  w^orld  can  save  such  a  part.  The 
utmost  that  even  the  best  of  methods  can  do  in  that 
event  is  to  assist  in  eliminating  the  infective  material  and 
then  help  in  the  reconstruction.  And  this  requirement 
Bier's  method  fulfils. 

Yet,  hyperemic  treatment  is  not  a  panacea.  It  is  just 
a  new  and  fascinating  but  very  powerful  therapeutic 
agent  on  a  physical  basis,  an  agent  which  has  its  indica- 
tions and  dosage,  the  same  as  any  other  remedy.  There  is 
much  to  learn  about  it  yet.     We  are  only  just  beginning 


214  bier's   HYPEREMIC  TREATMENT. 

to  appreciate  its  possibilities.  Although  it  has  been 
known  for  the  last  fifteen  years  as  an  efficient  remedy  in 
the  treatment  of  tuberculous  disease,  its  application  in 
the  treatment  of  acute  infections  is  of  but  comparatively 
recent  date;  it  is  still  on  trial  in  every  one  of  the  branches 
of  our  science. 

It  now  behooves  the  medical  profession  to  accept  what- 
ever proof  has  been  rendered,  and  to  work  conjointly  in 
further  developing  the  uses  of  this  promising  remedy,  to 
establish  the  indication  as  to  when  it  should  be  employed 
and  when  it  is  contraindicated. 

Individual  training,  tact,  and  judgment  are  essential  to 
success.  It  will  not  be  an  easy  task  for  the  surgeon  to 
decide  just  when  hyperemic  treatment  may  yet  be  employed 
in  a  somewhat  advanced  case,  and  when  prompt  operative 
intervention  be  imperative.  He  will  oftener  than  before 
move  along  the  borderline  between  conservative  and 
radical  treatment.  But  when  he  masters  the  details  of 
hyperemic  treatment  he  can  render  better  service  to  his 
patients  than  he  could  without  it.  He  will  be  able  oftener 
to  prevent  disaster  as  well  as  dangerous  and  protracted 
illness. 

It  must  be  remembered,  however,  that  hyperemic  treat- 
ment in  acute  diseases  requires  more  time  and  attention 
than  radical  work  with  the  knife,  chisel,  or  saw.  A  busy 
man  cannot  alone  undertake  the  treatment  of  many  such 
cases;  he  needs  trained  assistants  in  private  as  well  as 
hospital  and  dispensary  practice. 

If  such  assistance  be  not  obtainable,  it  were  better  not 
to  employ  the  method,  for  the  careful  supervision  of 
patients   under   hyperemic    treatment    is    of    paramoimt 


CONCLUSION.  215 

importance.  Many  of  the  failures  and  disappointments 
are  directly  due  to  improper  and  incorrect  use  of  the 
method;  in  fact,  actual  harm  has  resulted  therefrom. 
Even  in  our  hospitals  we  shall  have  much  to  contend  with 
in  this  respect.  With  our  ever  rotating  staff  of  phy- 
sicians and  nurses  a  correct  and  truly  beneficial  use 
of  Bier's  treatment  is  an  impossibility.  We  must  make 
special  provision  for  the  efficient  carrying  out  of  this  treat- 
ment, besides  giving  regular  practical  courses  in  hyperemic 
treatment  to  both  doctors  and  nurses.  In  other  words, 
we  must  adapt  the  method  to  the  usages  prevailing  at 
our  hospitals.  Matters  will  improve  as  soon  as  hyperemic 
treatment  is  taught  in  the  courses  of  college  instruction. 

An  arrangement  which,  in  our  opinion,  should  at  present 
be  made  in  every  hospital,  is  to  get  two  of  the  younger 
men  of  the  staff  to  volunteer  to  superintend,  during  their 
hospital  career,  the  proper  carrying  out  of  the  method  in 
all  cases.  The  same  should  be  done  in  the  various  depart- 
ments of  the  dispensaries.  The  small  sacrifice  of  time 
and  work  will,  by  virtue  of  the  experience  gained,  revert 
to  their  own  benefit  in  the  course  of  their  entire  future 
career. 

As  matters  are  at  present.  Bier's  treatment  is  a  step>- 
child  in  our  public  institutions;  then  it  would  probably 
become  one  of  the  favorites. 

Surely,  the  present  achievements  and  large  possibilities 
of  Bier's  treatment  call  for  united  action  on  the  part  of  the 
profession  to  further  facilitate  and  promote  its  usefulness. 


LITERATURE  OF  BIER'S  HYPEREMIC 
TREATMENT. 


Pare,  Ambroise:  Oeuvres  completes,  ii,  63,  30. 

1875. 

Nicoladoni:  v.  Diimreicher's  ^lethode  zur  Behandlung  dro- 
hender  Pseudarthrosen.  Wiener  med.  Wochenschrift, 
No.  5,  6,  7. 

1886. 
Thomas:  Contributions    to    Surgery  and   jMedicine,   part  vi. 
The  Principles  of  the  Treatment  of  Fractures  and  Dis- 
locations.    London,  1886. 

1887. 
Helferich:    Ueber     kunstliche    Vermehrung    der    Knochen- 
bildung.     Verhandl.  d.  deutsch.  Ges.  f.  Chirurgie,  1887^ 
II,  249.     Archiv.  f.  klin.  Chir.,  1887,  xxxvi,  873. 

1892. 

Bier :  Entstehung  des  Collateralkreislaufs.       Virch.   Arch., 

147,  1892. 
Bier  :  Ueber  ein  neues  Verfahren  der  konservativen  Behandl. 

V.  Gelenktbc.     Verh.  d.  dtsch.  Ges.  f.  Chir.,  1892,  i,  p.  91. 
Franck,  Franf  ois :  Ueb.  d.  ortlichen  u.  Allgemeinwirkungen 

d.    cutanen    Revulsion    auf    d.    Circulation.     Blatter    f. 

klin.  Hydrotherapie,  1892,  No.  11. 
217 


218  BIER'S    HYPEREMIC   TREATMENT. 

Metschnikoff :  LeQons  sur  pathol.  comparee  de  rinflamma- 

tion,  Paris,  1892. 
Pietrowski :    Studien   lib.    d.   peripheren   Gefassmechanism. 

Pfliiger's  Archiv,  vol.  55,  p.  240. 
Schrakamp  :  Ueb.  Entziindung.     Dissertat.,  Leipzig,  1892. 

1893. 

Amitin,  Sarah :  Ueb.  d.  Tonus  d.  Gefasse  bei  Einwirkung  d. 

Warme.     Ztschrift.  f.  Biologie,  1893,  vol.  35. 
Bier :  Behandlung  chir.  Tbc.  d.  Gliedmassen  mit  Stauungs- 

hyperamie.      Festschrift    f.   Esmarch,   Kiel    u.   Leipzig, 

1893. 
Buschke :  Ein  erfolgreicher  Versuch  mit  d.  Behandlung  v. 

Tbc.  d.  Extremitaten  nach  Bier.     Dtsch.  med.  Wchen- 

schrft.,  1893,  No.  35. 
Redlich :  Ueb.  einen  Fall  von  Hypertrophie  d.   1.   Beines. 

Wien.  med.  Wchschrft.,  1893. 
Richter :  Ueb.  neuere  Behandlungsmethoden  der  Tuberku- 

lose.     Schmidts  Jahrb.,  1893,  ccxxxix,  p.  180. 

1894. 
Bier :  Weitere  Mitteilungen  iib.  d.  Behandlng.  chir.  Tbc.  mit 

Stauungshyperamie.     XXIII.  Chir.  Congr.     Cntrlbltt.  f. 

Chir.,  1894,  No.  30.     Langenbeck,  Archiv,  1894. 
Buchner :  Ueb.  d.  natiirl.  Schutzkrafte  d.  Organism,  gegen- 

iiber  d.  Krankheitserregern.     Miinch.  med.  Wchnschrft., 

1894,  No.  30. 
Chvostek :  Ueb.  d.  Wesen  d.  paroxysmalen  Hamoglobinurie, 

Deuticke,  1894. 
V.  Esmarch  :  Discussion  zu  Bier.    23.  Chir.  Congr.,  1894, 1.  c. 
V.  Mikulicz  :  Ibid.,  1.  c. 
V.  Mikulicz :  Zur  Behandlung  d.  Tbc.  mit  Stauungshyp.  n. 

Bier.     Centrlbltt  f.  Chir.,  1894,  No.  12. 


LITERATURE.  219 

Miller :  Note  on  Bier's  New  Method  of  Treating  Strumous 

Diseases    of    the    Extremities    by    Passive    Congestion. 

Edinburgh  Med.  Journal,  February,  1894. 
Petersen :  Discussion  zu  Zeller.     23.  Cliir.  Congr.,  1894. 
Schwarz,  F. :   Versuch.  z.  Behandlung  tbc.  Gelenkaffection. 

mit  Stauungshyperamie.     Wien.  med.  Blatter,  xvii,  1894, 
Wagner :  Erfolg  d.  Behandlung  von  Knochen  und  Gelenk- 

tbc.  mit  Stauungshyp.  nach  Bier.     Dissertation,  Breslau, 

1894. 
Zeller :  Ueb.  Behandlung  chir.   Tbc.   durch  Stauungshyper- 

aemie.     23.  Chir.  Congr.  Centrlbltt.  f.  Chir.,  1894,  No.  30. 

Langenbeck's  Archiv,  vol.  48. 

1895. 

Bier :  Behandlung    d.    Gelenktbc.    mit   Stauungshyp.     Ber- 
liner Klinik,  1895,  No.  89. 
Goldscheider  und  Jacob  :     Beitrag  z.  Lehre  v.  d.  Phagocy- 

tose.     Fortschritte  d.  Med.,  1895,  xiii. 
V.  Kossa :  Die  Resorption  d.  Gifte  an  abgekvihlten   Korper- 

stellen.     Arch.  f.  experim.   Pathol,  u.  Pharm.,  vol!  36, 

p.  120. 
Lowy  u.  Richter  :  Ueb.  d.  Einfluss  v.  Fieber  und  Leukocytose. 

auf    d.    Verlauf    v.    Infectionskrankhtn.      Dtsch.    med. 

Wchenschrft.,  1895,  No.  15. 
Masuati :    Sopra  un  caso  di  sinosite  fungosa  del  ginocchio  e 

sul  metodo  di  Bier.     Rif.  med.,  1895,  xi,  32  and  33. 
Meyer,  W. :  The  Results  of  Bier's  ]\Iethod  in  the  Surgical 

Treatment  of  Tuberculous  Joint  Disease.     Transactions 

of   Orthopedic   Section,   Library,   New   York   Acad,    of 

Medicine. 
Negri :  Sulla  cura  della  tuberculose  degli  arti  colla  congest. 

Gazz.  med.  d.  Torino,  1895,  No.  16. 
Nicolai :  Ueb.  d.  Ligatur  d.  Nierengefasse,  Kiel,  1895. 


220  bier's  hyperemic  treatment. 

Penzo :  Ueb.  d.  Einfluss  d.  Temperatur  auf  d.  Regeneration 
d.  Zellen.  Moleschotts  Unters.  f .  Naturlehre  d.  ]\Ienschen, 
1895,  vol.  15. 

Sargeant :  Lancet,  1895,  p.  112. 

1896. 

Balli,  Ettore :  Ueb.  d.  Einfluss  lokaler  imd  allgem.  Erwarm- 

ung.     Dissertation,  Bern,  1896. 
Nbtzel :  Ueb.    d.   bactericide   Wirkimg   d.   Stauungshyp.   n. 

Bier.     Arch.  f.  klin.  Ghir.,  1896,  vol.  60,  1. 
Sibley,  Knoxley  :  Lancet,  1896,  p.  593. 
Woltersdorf :  Heilung    lokaler    Tbc.    durch    Stauungshyp. 

Dtsch.  med.  Wchnschrft.,  1896,  No.  41. 

1897. 
Bier  :  Die  Heilwirkung  d.  Hyperaemie.  Miinch.  med.  Wochen- 

schrift,  1897,  No.  32. 
Hahn :  L'eb.  d.  Steigerung  d.  natiirl.  Widerstandskraft  durch 

Erzeugung    v.    Hyperleukocytose.     Arch.    f.    Hygiene, 

1897,  vol.  28. 
Hamburger :  Over    den    heelzamen    invloed    van    veneuse 

stawing  en  outsteking  in  den  strijd  van  licham  tegen- 

bacterien.     Nederl.    Tijdschrift.    v.    Geneeskunde,  1897. 

Cntrlbltt.  f.  Bakt.,  1897,  p.  403.     Dtsch.  med.  Wchen- 

schrft.,  1897,  No.  49. 
Hamburger :  Opmerkingen   naar  aanleiding  van  en   opstel 

V.  Prof.  Spronck.     Neederl.  Tijdschrft.  v.  Geneeskunde, 

1897,  Nos.  13  and  17. 
Herz  :  Eine  neue  Methode  d.  Thermopalpation.     Wien.  med. 

Presse,  1897,  No.  7. 
Herz    und    Hiebel :  Ueb.    Thermopalpation.     Wien.    med. 

Presse,  1897,  Nos.  7  and  8. 
Jacoby :  Miinch.  med.  Wchenschrft.,  1897,  Nos.  8  and  9. 


LITERATURE.  221 

Masskow  :  Miiskelhypertrophie  nach  Venenthrombose.  Dis- 
sertation, Berlin,  1897. 

Sprouck  :  Over  d.  invloetl  van  veneuse  stawing  op  infectieuse 
processen.  Xederl  Tijdschrft.  v.  Geneeskunde,  1897, 
Nos.  10  and  16. 

Winternitz:  Die  Hydrotherap.  auf  physiol.  u.  klin.  Grund- 
lage,  vol.  i. 

1898. 
Bachmann  :   Der  Dyessche  Aderlass.     Dtsche.  Medicinalztg., 

1898,  Nos.  17-21. 
Baumler :  Discussion  zu  Mendelsohn:     Therap.  Verwertimg 

hoher   Temperaturen.     Congress   f.    inn.    Med.,   1898,  p. 

217. 
Bier  :  Die  Behandlung  des  chron.  Gelenkrheuma.  mit  heisser 

Luft.     Miinch.  med.  Wchnschrft.,  1898,  No.  38. 
Chlumsky  :    Die   Therap.  d.  Knochen-  iind  Gelenktbc.  nach 

Bier.     Wien.  klin.  Wchnschrft.,  1898,  No.  14. 
Hamburger :  Over  den  invloed  van  veneuse  stawing.     Cen- 

trlbltt.  f.  BacterioL,  1898,  p.  345. 
Henle :  Behandl.  d.  tbc.  Gelenke.     Beitr.  z.  klin.  Chir.,  vol. 

XX,  No.  3. 
Hildebrandt :  Ursachen    der    Heihvirkung    d.    Laparotomie 

bei  Bauchfelltbc.     Miinch.  med.  Wchnschrft,  1898,  Nos. 

51,  52. 
Huth :    Ueb.    Biersche    Stauungshyperaemie.      Dissertation, 

Bonn,  1898. 
Lindemann :  70.    \evs.  dtscher.   Naturforscher   und   Aerzte, 

1898.     Miinch.  med.  Wchnschrft.,  No.  46. 
Lbwenhardt :  Zur  Path,  und  Therap.  d.  gonorrh.  Gelenker- 

krankung.     Wien.  med.  Presse,  1898,  No.  45. 
Mendelsohn :  Ueb.  d.  therap.  Verwendung  sehr  hoher  Temp. 

Kongress  f.  inn.  Med.,  1898. 


222  bier's  hyperemic  treatment, 

Taylor :  On  the  Treatment  of  Neuralgia  by  Currents  of  Hot 
Air.     Lancet,  November,  1898. 

1899. 
Bier :  Ueb.  die  nach  u.  wahrend  der  v.  Esmarchschen  kijnst- 

liciien     Blutleere     eintretenden     Gefassveranderugn.    u. 

ihre   piiysiolog.    Erklarung.     Dtsch.   med.   Wchnschrft., 

1899,  No.  31. 
Bier :  Ueb.  versch.  Methoden  kiinstl.  Hyperaemie   zu  Heil- 

zwecken  hen^orzurufen.     Miinch.  med.  Wchnschrft.,  1899, 

Nos.  46  and  49. 
Buchner :  Zur  Lehre  v.  d.  nat.  Immunitat.     Miinch.   med. 

Wchnschrft.,  1899,  Nos.  39  and  40. 
Buchner :  Ueb.  d.  natiirl.  Schutzkrafte  d.  Organismus.      .     . 

Munch,  med.  Wchnschrft.,  1899,  Nos.  39,  40,  43. 
Goltz  iind  Ewald:  Der  Hund  mit  verkiirztem  Riickenmark. 

Pfiiiger's  Archiv,  1899,  vol.  63,  p.  362. 
Hamburger :   Ueb.  d.  Einfluss  v.  COj  auf  das  antibakteri- 

elle   Vermogen.   v.    Blut   mit  bes.   Beriicksichtigung  d. 

Stauung.     Virch.  Arch.,  1899,  clvi,  p.  329. 
Krause :  Erfahrung.    ueb.   therap.    Verwendung    iiberhitzter 

Luft.     Verh.  d.  Dtschn.  Ges.  f.  Chir.,  1899. 
Langemak :    Eine  eigenart.  Sensibilitatsstorung  nach  Bier- 

scher  Stauung.     Dtsch.  med.  Wchnschrft.,  1899,  No.  14. 
Lowenhardt :  Einwirkng.  heisser  Luft  auf  gonorrh.  Gelenke. 

XXVIIL  Congr.  f.  Chir.     Cntrlbltt.  f.  Chir.,  1899,  No.  17. 
Nbtzel :  Ueb.  d.  bactericide  Wirkung  d.  Stauungshyp.  nach 

Bier.     Congr.  f.  Chir.,  1899.     Cntrlbltt.  f.  Chir.,  No.  27. 
Wechsberg  :  Ueb.  d.  Einfluss  chem.  Gegenreize  auf  Entziind- 

ungen.     Ztschrft.  f.  klin.  Med.,  vol.  37,  p.  360. 
Weil :  Ueb.  d.  Einfluss  lokaler  Blutentziehungen   auf  Ent- 

ziindungen.     Ztschrft.  f.  klin.  Med.,  1899,  Bd.  37. 
Wilson  :  Hot  Air  in  Joint  Diseases.     Annals  of  Surgery,  1899, 

p.  155. 


LITERATURE.  223 

1900. 
Bachmann  :    Heilung  v.  Unterschenkelgeschwiiren  durch  d. 

Dyes'schen  Aderlass.     Therap.  Monatshefte,  April,  1900. 
Bier :  Ueb.    d.    Einfluss    kiinstl.    erzeugter    Hyperaemie    d. 

Gehirns  aiif  Epilepsie  und  Chorea.     Mitteil.  a.  d.  Grenzgeb. 

d.  Med.  u.  Chir.,  1900,  vii,  2  and  3. 
Czylharz  und  Donath  :  Ein  Beitrag  z.  Lehre  v.  d.  Entgiftung. 

Centralbltt.  f.  inn.  Med.,  1900,  No.  13. 
Frey :  Die   Massage   unter   d.    heissen    Luftdusche.     Dtsch. 

med.  Wchnschrft.,  1900,  No.  5. 
Frey  :  Ueb.   Behandlng.  v.   Neiiralgien  mit  der  Luftdusche. 

Arch.  f.  Pyschiatrie,  1900,  vol  33. 
Frey :  Ueb.  Behandhmg  mit  der  Luftdusche.     Therap.  IMo- 

natshefte,  June,  1900. 
Frey :  21.  Vers.  d.  Balneol.  Ges.  Frankfurt,  1900. 
Frey :  Dtsche.  Medicinalzeitung,  1900,  No.  35. 
Klapp :  Ueb.  d.  Behandlung  v.  Gelenkergiissen  mit  heisser 

Luft.     Miinch.  med.  Wchnschrft.,  1900,  No.  23. 
Marchand :    Ueb.  d.    natiirL    Schutzmittel    d.    Organismus, 

1900. 
Meltzer    u.    Langmann :  Wird    Strychnin    durch    lebendes 

tierisches  Gewebe  entgiftet?     Centralbltt.  f.  inn.    Med., 

1900,  No.  37. 
Noetzel :  Ueb.  d.  bactericid.  Wirkung  d.  Stauungshyp.  nach 

Bier.     Archiv  f.  klin.  Chir.,  1900,  Ix,  p.  1. 
Reineboth :  Exper.   Unters.   iiber  d.   Entstehungsmodus  d. 

Sugillationen  der  Pleura  infolge  v.  Abkiihlung.     Dtsches. 

Archiv  f.  kUn.  Med.,   1900,  vol.   62.     Cntrlbltt.  f,  inn. 

Med.,  1900,  No.  3. 
Reitler  :  Trocken.  Heissluftbeh.     Baden  bei  Wien,  1900. 
V.  Schlaffer :  Die  Losungsverhaltnisse  bei  Pneumonia  fibrin. 

und  Pneumonia  tuberc.     Beitr.  z.  Klinik  d.  Tuberculose. 

V.  Brauer,  1900,  v,  3. 


224  bier's  hyperemic  treatment. 

Thiem :  Ueb.  Thermotherapie  bei  der  Nachbehandlung  Un- 
fallverletzter.     Ztschrft.  f.  Unfallheilkunde,   1900,  No.  3. 

Walsh :  Hot-air  Treatment  of  Eczematous  Rheumatic  and 
Other  Affections,  Lancet,  1900,  p.  481. 

1901. 
Bier :  Ueb.    Anwendung    kiinstl.    erzeugter    Hyperamie    zu 

Heilzwecken.     XIX.  Kongr.  f.  inn.  Med.,  1901,  p.  213. 
Bier :  Die  Transfusion  v.  Blut.     Miinch.  med.  Wchnschrft., 

1901,  No.  15. 
Blecher :  Ueb.    d.    Einfiuss    kiinstl.    Stauung    auf    Gelenk- 

steifigkeiten  nach  Traumen.     Dtsch.   Ztschrft.  f.  Chir., 

1901,  Ix,  p.  250. 
Forchhaminer  :  Die  Finsentherapie  u.  ihr  gegenvv.  Stand  i.  d. 

Dermatologie.     VII.  Congr.  d.  dtschen.  dermatolog.  Ges., 

1901. 
Heinz :  Wirkung  ausserer  Reize  auf  die  Blutverteilung  in 

der  Tiefe.     XIX.  Congr.  f.  inn.  Med.,  1901. 
Kauffmann :  Ueb.   d.   Anwendung  einer  Luft  und  Wasser- 

massage  am  Auge.     Wchnschrft.  f.  Therap.  u.  Hygiene 

d.  Augen.,  vol.  v.  No.  22. 
Kleine  :  Ueb.  Entgiftung  i.  Tierkorper.     Ztschrft.  f.  Hygiene 

n.  Infectionskrkht.,  1901,  vol.  36. 
Kohlhardt :  Ueb.    Entgiftung    des    Cocains    im  Tierkorper. 

Dtsch.  Ges.  f.  Chir.,  1901,  vol.  ii. 
Meyer,  W. :  Tuberculosis  of  the  Testis.     Annals  of  Surgery, 

1901,  vol.  xxxiv,  p.  574. 
Perthes  :  Erfahrungen  bei  d.  Behandlung  d.  Empyems,  1901. 

Mitteilungen  a.  d.  Grenzgeb.  d.  Med.  u.  Chir.,  vol.  vii,  pp. 

4  and  5. 
Reineboth  u.  Kohlhardt :  Blutveranderung  infolge  v.  Ab- 

kiihlung.     Dtschs.  Arch.  f.  klin.  Med.,  1901,  vol.  65. 


LITERATURE.  IIo 

Ritter :  Behandl.  d.  Erfrierungen.     Dtsch.  Ztsclirft.  f.  Chir., 

vol.  58. 
Ritter :  Weitere  Erfahrungen  ii.   d.   Beh.   d.  Erfrierung  mit 

Hyperiimie.     Korresp.   Bltt.  d.  Vereins.  d.  Arzte.  Stral- 

simd. 
Schenk :  Tlierap.  d.  Lungentbc.  mittels  Stauimgshyp.    Wien. 

med.  Wchnschrft.,  1901,  Nos.  27  and  28. 
Schreiber  :  Ueb.  Heissluftapparate  iind  Heissluftbehandlung. 

Ztschrft.  f.  diat.  u.  physikal.  Therap.,  vol.  v,  No.  2. 
Ullmann :  Ueb.  d.  Heilwirkung  d.  durch  Warme  erzeugten 

Hyperamie  auf  chron.  imd  infectiose  Geschwiirsprocesse. 

Wien.  klin.  Wochenschrift,  1901,  No.  1. 

1902. 
Ambrosini :  L'aerothermie  dans  les  affections  des  permieres 

voies  respiratoires.     Ann.   d.   malad.   d.   I'oreille,    1902, 

xxvii,  No.  9. 
Bier :  Ueb.  prakt.  Anwendung  kiinstl.  erzeugt.  Hyperaemie. 

Therap.  d.  Gegenwart,  1902,  No.  2.      Cntlbltt.  f.  Chir., 

1902,  No.  50. 
Burwinkel :  Chron.  Herz  und  Limgenleiden  in  ihren  Wech- 

selbeziehungen.     Dtsche.  Medicinalztng.,  1902,  No.  34. 
Hofmeister :  Ein   neues   Massageverfahren,     Beitr.    z.    klin. 

Chir.,  1902,  vol.  36,  ii. 
Klapp :  Ueb.   Bauchfellresorption.  Mitt.   a.   d.   Grenzgeb.  d. 

Med.  u.  Chir.,  vol.  x,  Nos.  1,  2. 
Klapp :  Ueb.     parenchymat.     Resorption.     Arch.    f.   exper. 

Pathol,  u.  Pharmakol.,  vol.  47,  p.  86. 
Laspeyres :  Die  Behandlung  d.  nicht  tuberculosen  Gelenk- 

krkht.  mit  Bierscher  Stavmngshyperamie.     Cntralbltt.  f. 

d.  Grenzgeb.  d.  Med.  u.  Chir.,  1902,  No.  10. 
Lermoyez  et  Mahn  :  Nouvelles  recherches  concernant  Taction 

de  I'air  chaud.     Ann.  d.  malad.  de  I'oreille,  1902,  xxvii,  7. 
15 


226  bier's  hyperemic  treatment. 

Lick  :  Ueb.  d.  Einfluss  d.  arter.  Hyperaemie  auf  die  Regener- 
ation.    Cf.  Bier.  Hyperaemie. 

Link :  Vorschlag  zur  Behandliing  einseitiger  Tbc.  d.  Lunge 
mittels  Lagerung.     Ztschrft.  f.  Tbc.  u.  Heilstattenwesen, 

1902,  iii,  6. 

Pribram :  Chron.  Gelenkkrkhtn.  Nothnagel,  1902. 
Rautenberg :  Beitr.   z.   Kenntnis  d.  Heissluftbeh.     Ztschrf. 

f.  diat.  u.  physik.  Therap.,  vol.  vi,  Nos.  9,  10. 
Ritter:  Die  natuerlichen  Schmerzlin-dernden  Mittel  d.  Organ- 

ismus.     Verhandl.   d.   deutsher  Gesell.    f.    Chir.,    1902. 

Archiv.  f.  klin.  Chir.,  1902,  vol.  Ixviii. 
Roth :  Ein   neuer   Heissluftapparat.     Ztschrft.    f.    diat.  und 

physik.  Therap.,  1902,  No.  3. 
Schaffer  :  Die  Behandlung  v.  Gelenkergiissen  mit  heisser  Luft. 

Dissertation,  Greifswald,  1902. 
Sudeck :  Ueb.  acute  Knochenatrophie  nach  Entziindungen. 

Fortschritte  auf  d.   Gebiet  d.  Rontgenstrahlen,  vol.  v. 

1903. 
Bier,  A.:  Hyperaemie  als  Heilmittel.     Leipzig,  F.  C.  W.  Vogel, 

1903. 
Habs  :  Ueb.  d.  Biersche  Stauung.     Miinch.  med.  Wchnschrft., 

1903,  No.  22. 

Hanusa :  Ueb.  d.  Behandl.  lokal.  Erfrierungen  mit  pass.  u. 

activ.  Hyp.     Dissertation,  Greifswald,  1903. 
Herz :  Ueb.  d.  Temperaturverhaltnisse  chron.  erkrankt.  Ge- 

lenke  u.  gestauter  Glieder.     Berl.  klin.  Wchnschrft.,  1903, 

No.  20. 
Hoffheinz :  Ueb.  d.  Verhaltnisse  v.  Hyp.  und  Hyperidrosis 

b.    lokal.    Application    iiberhitzter    Luft.     Dissertation, 

Konigsberg,  1903. 
Klapp :  Experim.    Beitrage    z.    Kenntnis    der    Wirkung    d. 

Nebennierenpraparate.     Dtsch.  Ztschrft.  f.  Chir.,  vol.  71. 


LITKRATURE.  227 

Lommel :  Ueb.  d.  Tonus  d.  Gefasse.     Utsches.  Arch.  f.  klin. 

Med.,  vol.  Ixxviii. 
Luxembourg:  Ueh.  Biersche  Stauung.     ^liinch.  med.  Wchn- 

schrft.,  1903,  Xo.  10. 
Martin :  Zur   Lehre  v.   Einfluss  therm.   Amvendung.   auf  d. 

Gefas.s.system.     Ztschrft.    f.     diat.     u.    physik.    Therap., 

vol.  vii,  No.  8. 
Matthes  :  Lehrb.  d.  klin.  Hydrotherap.,  Jena,  1903. 
Meyer,  W.:  Tul^erculosis  of  the  Wrist-joint  Treated  by  Bier's 

^lethod.     Annals  of  Surgery,  1903,  vol.  xxxviii,  p.  106. 
Pick  :  Uel).  d.  Einfluss  mechan.  u.  therm.  Einwirkungen  auf 

d.  Blutstrom.     Ztschrft.  f.  Heilk.,  1903,  Xo.  2. 
Plaskuda :   Einige    alte    Behandlungsmethoden    i.    modern. 

Beleuchtung.     Dissertat.,  Greifswald,  1903. 
Schrakamp  :  Einige  Fragen  an  Ph3'siologen  unci  Pathologen. 

Schonberg,  1903. 
Sommer  :  Ueb.  d.  Wirkung  d.  Licht-  und  Warmest rahlung  auf 

d.  Hauttemperatur.     Berl.  klin.  Wchnschr.,  1903,  No.  40. 
M.  V.   Statzer :    Behandl.      d.     Erfrierungen.      Wien.     klin. 

Rundschau,  1903,  No.  49. 

1904. 

Bier  :  Ueb.  einige  Verbesserungen  hyperaemisierender  Appar- 

ate.     Miinch.  med.  Wchnschr.,  1904,  No.  5. 
Bier :  Behandl.    acut.    Eiterung.    mit   Stauungshyp.     Dtsch. 

med.  Wchnschrft.,  1904,  No.  32. 
Dehio :  Ueb.    Heilwirkung    des    kiinstlich    hervorgerufenen 

Fiebers.     Congr.  f.  inn.  Med.,  1904,  p.  478. 
Henle  :  Z.  Technik  d.  Anwendung  venos.  Hyperaem.     Cntl- 

bltt.  f.  Chir.,  1904,  No.  13,  p.  381.    . 
Koster  :  Niederrh.  Ges.  f.  Nat.  u.  Heilk.,  1904. 
Kothe  :  Studien  lib.  d.  Temp,  erkrankter  u.  hyperaemisierter 

Gelenke.     Miinch.  med.  Wchnschrft.,  1904,  No.  31. 


228  bier's  hyperemic  treatment. 

Langemak  :  Ueb.  Juteverbande.     iliinch.  med.  Wchnschrft., 

1904,  Xo.  43. 
Laqueur :  Z.  Beh.  d.  chron.  rheumat.  u.  d.  gonorrh.  Gelenk- 

erkrkng.    mit    d.    Bierschen    Stauungshyperaem.      Berl. 

klin.  Wochenschrift,  1904,  No.  36. 
Luxembourg :  Ueb.  Biersche  Stauung.     Miinch.  med.  Wchn- 
schrft., 1904,  No.  10. 
Matthes  :  Ueb.  d.  heutigen  Stand,  d.  Lehre  v.  d.  Reaction  im 

hydriatischen   Sinne.     Ztschrft.    f.   physik,     Therap.    u. 

Unfallheilk.,  1904. 
V.  Mikulicz  :  Vers.  lib.  Resistenzvermehrung  d.  Peritoneums* 

Congr.  f.  Chir.,  1904,  ii. 
Momburg :  Behandl.    d.   Fussgeschwulst    mit     Stauungshy- 
peraem.    Dtsche.  milit.-arztl.  Ztschrft.,  1904,  No.  1. 
Moritz :  Ueb.  d.  Einfiuss  d.  Bindens  der  Glieder  u.  d.  sog. 

Autotransfusion.     Dtsch.  med.  Wchnschrft.,  1904,  No.  31. 
Neumann :  Das  brisement   force   u.    seine   Nachbehandkmg 

mit    Thermotherapie.      Aerztl.  Mitt,  aus    Baden,   1904, 

vol.  58,  No.  2. 
Plaskuda :  Unters.    iib.    d.    Binden    d.    GUeder.     Dtsches. 

Arch.  f.  klin.  Med.,  vol.  80. 
Plaskuda:  Wien.  med.  Presse,  1904,  No.  46. 
RoUeston;  Clinical  Lectures,  1904,  p.  171. 
Schemel :  Beitrag  z.   Nachbehandlung  verletzter    Knochen. 

Dissertat.,  Leipzig,  1904. 
Schrakamp :  Ein  Gutachten  iib.  Entziindung.     Fortschritte 

d.  Med.,  1904,  No.  30. 
Tuszai :  Einige  Bemerkungen  iiber  Trockenheissluftbehand- 

lung.     Fortschritte  d.  Med.,  1904,  No.  20. 
Wiedmann  :  Beitrag  zur  Lehre  v.  d.  Behandlung  d.  traumat. 

Kniegelenksergusses.     Dissertation,  Bonn,  1904. 
Wiener :  Artificial  Hyperaemia  in    Surgeiy.     Lancet-Clinic, 

Cincinnati,  1904,  liii,  633. 


LITERATURE.  229 

1905. 

Arnsperger :  Erfahrungen   mit   Bierscher  Stauung  1).    akut. 

Entzuiulung.     Miincli.  med,  Wchnschrft.,  1905,  No.  52. 
Bauer :  Jun    Speculum    zur   Staiuuig«l)eliandl.     Wien.    med. 

Wclmschrft.,  1905,  No.  48. 
Bauer :  Die   Biersche  Stauung  i.   d.   Gyniikol.     Wien.    klin. 

Wchnschrft.,  1905,  No.  47. 
Baum :  Stauungstherap.    b.    acut    eitriger    Sehnenscheiden- 

phlegmone.     Med.   Ges.   in   Kiel.     Miinch.   med.   Wchn- 
schrft., 1905,  No.  19. 
Beckman  :  Behandhmg  v.  Krankhtn.  mit   kiinstl.  Hyperaem. 

nach  l^ier.     Hygiea,  1905,  No.  5,  p.  481. 
Beckman  :  The  Treatment  of  Diseases  l^y  Artificial  Hyper- 

aemia,  Hygiea,  1905,  v,  p.  781. 
Bering :  Ein  neuer  Heissluftmotor.     Med.  Klinik,  1905,  No. 

18. 
Berner :  Die  durch  d.  Bier-Klappsche  Stauungsbehandl.  be- 

wirkte     Abkiirzung    d.    Behandlungsdauer.     Ztschr.     f. 

Bahnarzte.      Melsungen,  1905-6,  i. 
Berlin  :  Behandhmg  acut.  Eiterungen  mit  Bierscher  Stauung, 

Miinch.  med.  Wchnschr.,  1905,  No.  29. 
Bie  :  Anwendung  d.  Lichts  in  d.  Med.,  Wiesbaden,  1905. 
Bier  :  Behandl.  acut.  Eiterungen  mit  Stauungshyp.     Miinch. 

med.  Wchnschrft.,  1905,  No.  5-7. 
Bier:  Behandl.  d.  Gelenktbc.    Arthritis  deform.,  etc.    Congres 

de  la  societe  internationale  de  chirurgie,  Briissel,  1905. 
Bier :  Behandl.  acut-entziindl.  Krkhtn.  mit  Stauungshyper- 

aemie.     XXXIV.   Congr.    f.   Chir.     Cntrlbltt.    f.    Chir., 

1905. 
Bier :  Das  Verfahren  d.  Stauung  bei  akut  entziindl.  Krank- 

heiten.     Langenbeck  Archiv,  1905,  Bd.  77,  No.  1. 
Bier :  Die   Bedeutung  d.    Blutergusses  fiir  d.    Heilung  des 

Knochenbruches.     Med.  Klinik,  1905,  Nos.  1  and  2. 


230  bier's  hyperemic  treatment. 

Bier  und  Klapp :  Stau-  unci  Saugapparate  zur  Behandlung 

entziindl.  Erkrankungen.    Arztl.  Polytechnik,  1905,  No.  8. 
Braun :  Die  Lokalanaesthesie,  Leipzig,  1905,  p.  177. 
Breuer :  Le  traitement  par  I'hyperemie  de  Bier.     Bull.  med. 

de  Quebec,  1905-6,  vii. 
Brunn,  Max  v.  :  Ueb.    d.  Stauungsbehandl.    b.  acut.  Ent- 

ziindung  n.  d.  Erfahrung.  d.  Brunssehen  Klinik.     Beitr.  z. 

klin.  Chir.,  vol.  46,  1905,  p.  845. 
Bum  :  Die  Behandlung  v.  Gelenkerkrankungen  mit  Stauung. 

Wien.  med.  Pr.,  1905,  Nos.  3-4. 
Burwinkel :  Discussion  zu  Laqueur.     Berl.  klin.  Woch.,  1905, 

No.  23. 
Clement :  L'hyperhemie  en  th^rapeutique  (methode  de  Bier). 

Rev.  med.  Suisse  Rom.,  1905,  No.  12. 
Danielsen  :  Ueb.  d.  Bedeutung  d.  Bierschen  Stauung  b.  acut, 

Entziindung.     Miinch.  med.  Woch.,  1905,  No.  48. 
Derlin :  Beitr.  z.  Behandl.  acut.  Eiterungen  mit   Bierscher 

Stauung.     Miinch.  med.  Woch.,  1905,  No.  29. 
Eiselsberg  :  Discussion  zu  Ranzi,  1.  c. 
Eversmann ;  Biersche  Stauung  i.  d.  Gynakologie.     Cntrbltt. 

f.  Gynak.,  1905,  No.  48. 
Fischer,  C. :  Zur  therap.  Verwertung  d.  Stenosenatmens  in  d. 

Lungentbc.      Ztschrft.  f.  diat.  u.  physik.  Therap.,  1905, 

ix,  4. 
Frankel,    J.  :   Verbesserung    d.     Bierschen    Saugapparate. 

Cntrlbltt.  f.  Chir.,  1905,  No.  25. 
Frankl :  Discussion  zu  Ranzi,  1.  c. 
Frommer  :  Bisherige  Ei-fahrungen  m.  d.  Bierschen  Stauungs- 

hyp.  b.  chron.  Eiterungen  u,  i.  d.  postoperativ.  Behand- 
lung.    Przeglad  lekarski,  1905,  No.  33. 
Girard :  L'hyperemie  dite  de  Bier.     Rev.  m6d.  de  la  Suisse 

Rom.,  1905,  No.  25. 
Griinbauin  :  Technik  d.  Stauungshyp.   Therap.  d.  Gegenwart, 

1905,  No.  3. 


LITER  ATURP].  231 

Habs :  Erfahrungen    mit    Bierseher    Stauung.     Wien.    klin. 

JUmtlschau,  1905,  No.  46. 
Heile :  Die    Autolyse   als   Heilfactor.     Arch.    f.    klin.    Chir., 

Ixxvii,  1905,  No.  4. 
Heile :  Verb.  d.  Chir.   Kongr.,   1905,  p.   727.      Cntrlbltt.  f. 

Chir.,  1905,  No.  30. 
Heine:    Ueb.    d.    Beh.    d.  acut.    eitrigen    Mittelohrentziind. 

mittels  Stauiingshyp.  n.  Bier.     XIV.  Vers.  d.  otolog.  Ges. 

Miinch.  med.  Woch.,  1905,  No.  29. 
Heine :  Behandl.    d.    akut.    eitrig   Mittelohrentziindung   mit 

Stauung.     Berl.  klin.  Woch.,  1905,  No.  28. 
Hirsch :  Behandl.   d.   Arthrit.   gonorrh.   mit  Biers  Stauung. 

Berl.  klin.  Woch.,  1905,  No.  39. 
Hochhaus :  Behandl.   acut.  Halsaffect.  mit    Stauungshyper- 

aem.     Miinch.  med.  Woch.,  1905,  No.  39. 
Hochhaus :  Behandl.    acut.    Halsaffect.  mit   Stauungshyper- 

aem.     Therap.  d.  Gegenw.,  October,  1905. 
Hofmann :  Veranderung    im    Granulationsgewebe    fistuloser 

fungoser    Hercle    durch    Hyperamie    mit    Saugapparat. 

Miinch.  med.  Woch.,  1905,  No.  39. 
Honneth :  Ueb.  d.  Wert  d.  Sondermannschen  Saugapparates 

zur  Diagnose  u.  Therap.  d.  Nasenerkrankungen.    Miinch. 

med.  Woch.,  1905,  No.  49. 
Jansen :  Entziindung  d.  Mittelohrs  u.  ihre  Behandl.  Dtsche. 

Klinik  am  Ende  d.  XIX.    Jahrhunderts,  vol.  viii,  p.  255. 
Jerusalem  :  Ztschrft.  f.  orthop.  Chir.,  vol.  xxi,  p.  265. 
Jerusalem  :  Discussion  zu  Ranzi,  1.  c. 
Joseph :  Einige  Wirkungen  d.  natiirl.  Odems   u.  d.  kiinstl. 

Odemisirung.     Miinch.  med.  Woch.,  1905,  No.  40. 
Joynt :  Notes  on  a  Case  of  Pressure  Stasis.     Lancet,  1905, 

i,  856. 
Keppler :  Beh.  entziindl.  Erkrankng.  v.  Kopf  u.  Gesicht  mit 

Stauungshyperaem.  Miinch.  med.  Woch.,  1905,  Nos.45-47. 


232  bier's  hyperemic  treatment. 

Keppler :  Behandl.  eitriger  Ohrenerkrankung  mit   Stauung. 

Ztschrft.  f.  Ohrenhlkde.,  1905,  No.  3. 
Key :  Om  behandling  af  akuta  varbildning  med.  hyperiimi. 

Allm.  sven.  Lakartidn.,  1905,  ii,  p.  485. 
Klapp  :  ]\Iobilisirung  versteifter  imd  Streckung  contractiirirter 

Gelenke    durch    Saugapparate.     ]\Iunch.    med.    Woch., 

1905,  No.  17. 
Klapp :  Anwendung  d.  mobilisirenden  Wirkung  der  Hyper- 

amie  auf  skoliotische  Versteifungen.     Dtsch.  Ztschrft.  f. 

Chir.,  vol.  79,  No.  4-6. 
Klapp  :  Stauungshj'peramie  bei  Mastitis.     Med.  Klinik,  1905, 

No.  28. 
Klapp  :  Behandl.  entziindl.  Erkrkg.  mit  Saugapparat.   Miinch. 

med.  Woch.,  1905,  No.  16. 
Lamberger :  Ueb.  locale  Heissluftbehandlung.     Wien.  med. 

Pr.,  1905,  No.  1  u.  2. 
Laqueur  :  Zur  physik.  Behandl.  d.  gonorrh.  Gelenkerkrankung. 

Berl.  klin.  Woch.,  1905,  No.  23. 
Leser :  Ueb.    eine    Beobachtung    im    Gefolge    d.    Bierschen 

Stauung  bei  acuteitr.  Processen.     Cntrlbltt.  f.  Chir.,  1905, 

No.  17,  p.  470. 
Lommel :  Ueb.  d.  Viscositat  d.  menschl.  Blutes  bei  Schwitz- 

proceduren.     Dtschs.  Arch.  f.  klin.  Med.,  Ixxx. 
Lessen :  Biersche   Stauung  bei   Sehnenscheidenphlegmonen. 

Miinch.  med.  Woch.,  1905,  No.  31. 
Liithi :  Ueb.   experim.   venose    Stauung  i.   d.   Hundeschild- 

driise.     Mitteil.  a.  d.  Grenzgeb.  d.  Med.  u.  Chir.,  xv,  3  und 

4,  1905. 
Manninger :  The  Treatment  of  Loc.  Infect,  by  Graduated 

Plethora.     Groosi  hetil.  Bud.,  1905,  xlix,  815,  836,  859, 

880. 
Marcuse  :  Beitr.  z.  Heisslufttherap.  Ztschrft.  f .  diat.  u.  physik. 

Therap.,  1905,  p.  323. 


LITERATURE.  233 

Marcuse :  Heissluftapparate    unci    Heissluftbeh.     Url^an    u. 

Schwarzenberg,  1905. 
Martin  :  Ueb.  d.  Bedeutung  des  Verschlusses  d.  Ostien  bei 

entziindl.    Erkrkgn.    d.    Kieferhohle.     Monatsschrft.    f. 

Ohrenhlkde.,  1905,  No.  2. 
Minkowski :  Uie  Behandlimg  d.  Gicht.     Dtsch.  med.  Woch., 

1905,  No.  11. 
Momburg :  Ueber  Stauungshyperamie  b.  d.  Beh.  d.  Fussge- 

schwulst.     Cntrlbltt.  f.  Chir.,  1905,  No.  6. 
Mosetig  :  Discussion  zu  Ranzi,  1.  c. 
Necker :  Discussion  zu  Ranzi,  1.  c. 
Payr :  Wolfler's  Erysipelbeliandl.     Wien.  med.  Wocli.,  1905, 

No.  38. 
Penzo  :  Sulla  influenza  dell  iperemia  passiva  nelle  rigenera- 

zione  cellulare.     Atti  d.   reale  istituto  ven.   d.   scienze. 

T.  Ixiv,  p.  ii,  1905. 
Prym  :  Z.  Behandl.  d.  entziindl.  Erkrank.  d.  Tonsillen.  Mlinch. 

med.  Woch.,  1905,  No.  48. 
Ranzi :  Ueb.   d.   Biersche  Stauung  bei   akut   Entziind.   mit 

Saugapparat.  Ges.  d.  Arzte.  Wien.     Miinch.  med.  Woch., 

1905,  No.  49. 
Ranzi :  Behandl.  v.  eitrigen  Processen  durch  Stauung  und 

Saug.  nach  Bier.     Wien.  med.  Woch.,  1905,  No.  47. 
Rautenberg :  Experim.  Untersuchungen  ueb.  aktive  Hyper- 

amie.     Ztschrft.  f.  diat.  und  physik.  Therap.,  1905,  p.  333. 
Ribbert :  Die  Bedeutung  d.  Entziindung.     Bonn,  1905. 
Ritter :  Die  Entstehung  d.  entziindl.  Hyperamie.    Mitt.  a.  d. 

Grenzgeb.  d.  Med.  u.  Chir.,  1905,  No.  3. 
Rube :  Studie  ueb.  d.  Geschichte  d.  Schropfapparate.     Dis- 
sertation, Bonn,  1905. 
Rudolph :  Die  Biersche  Stauung  i.  d.  gynak.  Praxis.     Cntrl- 
bltt. f.  Gynak.,  1905,  Nos.  39,  40. 


234  bier's  hyper emic  treatment. 

Sabzer:  Congestive  Hyperemia  in  the  Treatment  of  Acute 

Suppuration.     Lancet-Clinic,  Cincinnati,  1905. 
Sick :  Methode  acute  Eiterungen  m.  Stauung  zu  behandeln. 

Miinch.  med.  Woch.,  1905,  No.  11. 
Sondermann :   Saugtherap.   b.   Lupus.     Monatsh.   f.   prakt. 

Dermat.,  1905,  vol.  44,  No.  1. 
Sondermann :  Saugtherap.  b.  Ohrenerkrkgn.  Arch.  f.  Ohren- 

hlkde.,  1905,  vol.  64,  No.  1. 
Sondermann :  Eine  neue  Method,  z.  Diagnose  u.  Therap.  d. 

Nasenerkrkg.     Miinch.  med.  Woch.,  1905,  No.  1. 
Spiess  :  Die  therap.  Verwendung  d.  negativen  Drucks  b.  Beh. 

d.  trocknen  atroph.  Katarrhe  d.  Nase.     Arch.  f.  Laryngol. 

u.  RhinoL,  1905,  vol.  17,  No.  2. 
Stich :  Z.  Beh.  akut.  Entziindungen  mittels  Stauungshyper- 

aem.     Berl.  klin.  Woch.,  1905,  Nos.  49,  50. 
van  Swieten :  Trois  malades  gueris  par  la  methode  de  Bier. 

Presse  med.  beige,  1905,  p.  1049. 
V.  Tiling  :  The  Treatment  of  Gonorrheal  Arthritis.     Journ.  of 

Am.  Med.  Assoc,  1905,  29,  iv. 
Tillmanns :  Ueb.  Behandl.  durch  venose  Stauung,     Dtsch. 

med.  Wchnschrft.,  1905,  No.  4. 
UUmann :  Discussion  zu  Ranzi,  1.  c. 

Ullmann  :  Hodentuberculose.  Wien.  klin.  Woch.,  1905,  No.  47. 
Volk :  Discussion  zu  Ranzi,  1.  c. 
Volk :  Therap.    d.    entziindl.    Leistendriisen.     Wien.    med. 

Presse,  1905,  Nos.  48,  49. 
Wassermann :  Behandl.  d.  Lungentbc.  und  passiver  Hyper- 

amie.     77.  Vers.  Dtsch.  Naturf.  u.  Arzte.      Wien.  med. 

Woch.,  1905,  No.  43. 
Wechsberg  :  Discussion  zu  Ranzi,  1.  c. 
Weinlechner  :  Discussion  zu  Ranzi,  1.  c. 
Wessel :  Behandl.  v.  Fractura  radii  mit  Stauungshyperamie. 

Nordisk.  Tidsskrift.  for  Terapi,  vol.  iv,  No.  12. 


LITERATURE.  235 

Winternitz :  Die    Fluxion    al.s    Heilmittel.    Blatter    f.    klin. 

Hydrotherap.,  1905.  xv,  p.  117. 
Witzel :  Die  Biersche  Stauung  iind  deren  Amvendung  i.  d. 

Zahnheiikunde.     Zahnarztliche  Rundschau,  vol.  14,  Xos. 

19-22. 

1906. 
Adams :  The   \'alue   of   Bier  Treatment.     New   York  Med. 

Jour.,  1906,  Ixxxiv,  p.  336. 
Alexander :  Verh.  d.  dtsch.  Otol.  Ges.,  Jena,  1906,  p.  26. 
Auffert :  La  methode  de  Bier  dans  la  tuberc.  et  les  infections 

aigues.     Rev.  d'Orthoped.,  1906,  2.  s.  vii,  p.  481. 
Babler :  Passive  Hyperemia.      St.   Louis  Cour.  Med.,   1906, 

xxxiv,  349. 
Bardenheuer :  Chir.  Congr.,  1906. 
Bauer :  Ueb.    d.    Behandl.    d.    Mastitis   mit   Saugapparaten. 

Dissertat.,  Bonn,  1906. 
Bauman :  Hyperaemia  as  a  Therap.  Agent.     Cleveland  Med. 

Jour.,  1906,  V,  127. 
Baumbach :  Stauungsbehandl.  acut  Entzlindung  nach  Bier. 

Wien.  med.  Woch.,  1906,  No.  28. 
V.  Baumgarten :  Experim.   ueb.   d.   Wirkung   d.    Bierschen 

Stauung  auf  infectiose  Processe.     Miinch.  med.  Woch., 

1906,  No.  48. 
Beer :  The  Therap.  Value  of  Artificial   Localized  Hyperem. 

Med.  Record,  August  25,  1906. 
Berard  :  De  Tapplieation  de  la  methode  de  Bier  dans    les 

lesions  inflammatoires.     Lyon  med.,    1906,   cvi,   p.    934. 
Bestelmeyer :  Erfahrungen  iib.  d.  Behandl.  acut.  entziindl. 

Processe  mit  Stauungshyperaemie  n.  Bier.     Miinch.  med. 

Woch.,  1906,  No.  14. 
Biehler  :  Hyperaemie.  Kron.  lek.  Warszawa,  1906,  xxvi,  p.  428. 
Bier    u.    Lossen :  Hyperaemisirende    Behandlung.     Miinch. 

med.  Woch.,  1906,  No.  30. 


236  bier's  hyperemic  treatment. 

Blanc  :  Die  Biersche  Stauung  bei  Gelenkaffectionen  d.  Bander. 

Soc.  Ginec.  Espan.,  Nov.  28,  1906.     Rev.  d.  med.  y  Cir. 

Prat.,  1907,  7,  iv. 
Bohme :  Kurzer  Bericht  lib.   durch   Biersche  Stauung  mit 

Saugglocken  bei  Bubonen  erzielte  Erfolge.     Cntrlbltt.  f. 

d.  Krankh.  d.  H.  u.  Sexualorgane,  1906,  No.  7. 
Bonheim :  Ueb.  Behandl.  acut.  Entziindung  d.  Hyperamie 

n.  Bier.  Aerztl.  Verein.  Hamburg.     ^liinch.  med.  AVoch., 

1906,  No.  18. 
Bonheim :  Dtsch.  med.  Woch.,  1906,  No.  36. 
Boshouwers  :  Saugbehandl.  nach  Bier — Klapp  bei  Erosionen 

d.  Portio  vaginalis.    Nederl.  Tydschrif t  voor  Geneeskunde, 

1906,  No.  7. 
Bradford :  The  Hyperemic  Treatment  of  Inflamed  Tissues. 

Bost.  Med.  and  Surg.  Journ.,  1906,  cliv,  p.  671. 
Breiger :  Oertliche  Lichtbeh.  u.  Biersche  Stauung.     Ztschr. 

f.  physik.  u.  diat.  Therap.,  1906,  x,  p.  7-48. 
Brewer :  The  Bier  Treatment  by  Hyperemia.     Med.  Rev., 

New  York,  1906,  Ixix,  290. 
Brunn :   Biersche    Stauung    u.  Krankenpflege.     Ztschrft.  f. 

Krankenpflege,  1906,  xxviii,  p.  51. 
Burk  :  Behandl.  mit  Stauung  b.  Phlegmon.    Jahrb.  d.  Hamb. 

Staatskr.,  1906-07,  xi,  pt.  2. 
Canon :  Congr.  d.  dtsch.  Ges.  f.  Chir.,  1906. 
Cathcart :  On  Bier's  Treatment  of  Acute  Inflamm.  by  Passive 

Congestion.     Tr.  Med.  Chir.  Soc.  Edinb.,  1906,  xxv,  p.  150. 
Cathcart :  Scottish  Med.  and  Surg.  Jour.,  April  1,  1906. 
Clement :  L'aspiration  en  therapeutique  chirurgicale.  Archiv. 

gen.  d.  Med.,  1906,  No.  36. 
Clement :  L'hyperemie  en  therapeutique.     Rev.  med.  Suisse 

Rom.,  xxv,  No.  12. 
Codman :  On  the  Bier  Treatment  of  Infections  and  Septic 

Wounds    of    the    Extremities.     Bost.    Med.    and    Surg. 

Journ.,  1906,  434. 


LITERATURE.  237 

Colle   et   Folet :    Methode  de   Bier.     Echo.  med.   du  nord, 

Lille,  1906,  x,  175. 
Colley  :  Beol).  und  Betrachtgn.  lib.  d.  Behandl,  acut  eitrig. 

Processe  mit  Bierscher  Stauimg.      Miinch.  med.  Woch., 

liii,  6,  p.  257,  1906. 
Cossart :  Sur  les  effets  therap.  de  la  methode  de  Bier.     So- 

ciete  d.  medecins  praticiens  de  Riga,  10,  iv,  1906.     Presse 

medicale. 
Dauwe :    La  therapeutique   par  hyperemie.     Gaz.    d.   hop., 

1906,  Ixxix,  p.  975. 
Debeyre  :  Methode  de  Bier.   Echo  med.  du  nord,  Lille,  1906,  x. 
Delageniere  :  La  methode  de  hyperemie  de  Bier.     Journ.  d. 

med.  et  de  Chir.,  1906,  No.  18. 
Deutschlander :  Behandl.  d.  Knochenbriiche  mit  Stauungs- 

hyp.     Cntrlbltt.  f.  Chir.,  1906,  No.  12. 
Deutschlander :  Staiumgshyp.   bei  orthop.   Operationen.  V. 

Congr.  d.  Ges.  f.  orthop.  Chirurgie,  1906. 
Deutschlander :  Ueb.  d.  Anwend.  d.  Staimngshyperamie  bei 

orthop.  Chir.     Zt.  f.  arztl.  Fortbildung,  1906,  iii. 
Donati  e  Delfino  :  SuU'  influenza  d'ella  stasi  alia  Bier  nel 

processo     di    guarizione    delle    ferite    della    cartilagine 

auricolare.     Bif.  med.,  xxii,  47,  p.  1289,  1906. 
Elting :  Hyperemia  in  the  Treatment  of  Acute  Infections. 

Albany  Med.  Ann.,  1906,  xxvii. 
Enderlen :  Beh.   d.   Furunkels,    1906.     Dtsch.   med.   Wchn- 

schrft..  No.  42. 
Englander  :  Brustdriisenentziindung  b.  einer  Stillenden.     Cn- 
trlbltt. f.  Gynak.,  1906,  No.  16. 
Esch :  Von  der  Antiphlogose  zur  Hyperaemisirung,  von  der 

Kalte  zur  Warmebehandlung.     Arch.  f.  physik.  u.  diat. 

Therap.,  1906,  viii,  p.  322. 
Eversmann :  Die    Klappsche    Saugbehandl.    bei    eiternden 

Hautwunden.     Cntrlbltt.  f.  Gynakol.,  1906,  No.  4. 


238  bier's  hyperemic  treatment. 

Faure  :  La  methode  de  Bier.     Presse  med.,  1906,  xiv,  51. 
Fein  :  Die  Ozaena  u.  d.  Stauungstherap.  n.  Bier.     Wien.  klin. 

Wchnschrft.,  1906,  No.  31. 
Feleki :  Mesterseges  verboseg  alkalmazdsa  egyes  nemi  bajok 

orvosla  saban.     Orvosi  hetil.,  1906,  2,  p.  1055. 
Ferrari :  Sulla  stasi  alia  Bier.     Gazz.  d'osp.   Milano,  1906, 

xxvii. 
Fichera :  L'iperemia  da  stasi  nelle  infezioni  acute.     Policlin. 

Roma,  1906,  xiii,  p.  519. 
Fichera  :  II  metodo  di  Bier  nelle  infezioni.     Bull.  d.  r.  Accad. 

med.,  1906,  xxxii,  p.  430. 
Fischer,  M.  :  Zur  Anwendung  der  Stauungshyperamien.  Bier. 

Dtsch.  klin.  therap.  Wchnschrft.,  1906,  xiii,  p.  1325. 
Fleischmann :  Ueb.  d.  Behandlung  eitriger  Mittelohrerkrkg. 

mit    Bierscher    Stauung.      Monatsschrft.    f.    Ohrenheil- 

kunde,  1906,  No.  5. 
Frankel,  J. :   Zur    Behandlg.    v.    Handversteifugn.    mit    d. 

Bierschen  Saugapparat.     Ztschrft.  f.  diat.  u.  physikal. 

Therap.,  1906,  ix,  10. 
Frankl :  Die  physikalische  Heilmethode  in  der  Gynakologie. 

Wien.  klin.  Wchnschrft,  1906. 
Frommer :  Therap.   Hyperemia  by  Bier's  Method,   with  a 

Special    View    of    Post-operative    Wounds    and    Senile 

Gangrene.     Przegl.  lek.  krakow,  1906,  pp.  249,  280,  292, 

314,  330,  347. 
Frommer :  Wien.  klin.  Wchnschrft.,  1906,  No.  8. 
Fiirst :  Haemostase  bei  Blutungen  d.  gastro-intestinal  und 

Urogenitalsphare.     Dtsch.  klin.  therap.  Wchnschrft,  1906, 

iii,  p.  591. 
Gangele,  K. :  Zur  Behandlng.  d.  tbc.  Fisteln  mit  d.  Bierschen 

Saugglocke.     Cntrlbltt.  f.  Chir.,  1906,  xxxiii,  p.  775. 
De  Gaulejac  :  La  methode  de  Bier.     Journ.  de  physiotherap., 

1906,  iv,  p.  412. 


LITERATURE.  239 

Gebele  und  Ebermeyer :  L  eb.  d.  Behandkmg  d.  Gelenktbc. 

Miinch.  med.  Woch.,  1906,  No.  13. 
Gobel :   Ueb.  d.  hyperleukocytose  erregende  Wirkung  haut- 

reizender  Mittek     Med.  Klin.,  1906,  Xo.  1. 
Gorse  :  Contril).  a  I'etude  de  la  methode  de  Bier.     Toulouse, 

1906,  140,  p.  8°. 
Goyanes  :  Ein  nach  d.  \'ei'fahren  v.  Bier-Klapp  geheilter  Fall 

von  Brustwarzenentziindng.     Rev.  d.  Med.  y.  Chir.  pra- 

ticas,  1906,  Xo.  934. 
Gramenitzki :   Treatment   l^y  Passive   Hyperemia   by  Bier's 

Method.     Russk.  Vrach,  1906,  v,  p.  1107. 
Grawitz:  Klin.  Pathol,  d.  Blutes,  p.  211,  1906. 
Grube  :  Die  Anwendung  d.  Hyperaemie  nach  Bier  bei  einigen 

Erkrkngn.    d.    Diabetiker.     Miinch.    med.  Wchnschrft.? 

1906,  Xo.  29. 
Guth  :  Behandlng.  entziindl.  Erkrkng.  mit  Stauungsbinden  u. 

Saugapparaten.    Prag.  med.  Wchnschrft.,  1906,  vol.  31, 

Xo.  3. 
Guyot :  Des  indications  de  la  methode  de  Bier  en  Oto-rhin- 

ologie,  Clinique,  Brux,  1906,  xx. 
Guyot :  Rev.  med.  de  la  Suisse  Rom.,  1906,  Xo.  5. 
Habs  :  Congress  d.Ges.  f.  Chir.,  1906,  Xo.  28.  Cntrlbltt.  f.  Chir. 
Hausler :  Ibid. 
Hasslauer  :  Die  Stauungshyperamie  bei  Behandlng.  v.  Ohrei- 

terungen.     Miinch.  med.  Woch.,  1906,  Xo.  34. 
Hauffe :  Gelenkrheuma  ohne  Salizyl.  behandelt.     Therap.  d. 

Gegenwart,  1906,  X.  F.,  viii,  2. 
Haymann :    Ueb.    Stauungstherapie.     Intern.    Cntrlbltt.    f. 

Ohrenhlkde.,  1906,  p.  113. 
Heennann  :  Zur  konservativ.  Beh.  d.  Nebenhohleneiterungen. 

Miinch.  med.  Woch.,  1906,  No.  24. 
Heermann :  Ueb.  partielle  Stau-  und  Druckbehandlung  bei 

Entziindungen.     Dtsch.  med.  Wchnschrft.,  1906,  X'^o.  18. 


240  bier's  hyperemic  treatment. 

Heidenhain :  35.  Congr.  d.  Ges.  f.  Chir.,  i,  p.  237. 

Heller :  Behandl.    aciit.    entzimdl.    Processe    mit    Bierscher 

Stauung.     Med.  Klin.,    1906,  No.  22,  and  Dtsch.  med. 

Woch.,  1906,  No.  29. 
Herhold :  Stauungshyperamie   bei   acut   eitrigen   Processen. 

Miinch.  med.  Wchnschrft.,  1906,  No.  6. 
Hesse :  Staimngshyperam.  im  Dienste  der  Augenheilkunde. 

Cntrlbltt.  f.  prakt.  Augenhlkde.,  xxx,  1906,  167. 
Heyde :  Experimente  lib.  Biersche  Stauung,     Verb.  d.  dtsch. 

Ges.  f.  Chir.,  Bd.  x,  1906. 
Homberger :  Eine  physio-pat  hoi.  Studie  lib.  venose  Hyper- 

amie.     Arch.  f.  klin.  Chir.,  1906,  Ixxx. 
Hoppe  :  Einwirkung  d.  Stauungshyperam.  als  sogen,  Kopf- 

stauung   (n.   Bier)   auf  d.   normale  Auge  u.  d.   Verlauf 

gewisser  Augenkrkhtn.     Klin.  Monatsblatter  f.  Augen- 
hlkde., October,   1906;    and  Miinch.   med.  Wchnschrft., 

1906,  No.  40. 
Isemer :  Klin.  Erfahrungen  mit  d.  Stauungshyperamie  nach 

Bier  bei  Behandl.  d.  Otitis  media.     Arch.  f.  Ohrenhlkde., 

1906,  vol.  68,  Nos.  1-3;  vol.  69,  Nos.  1,  2. 
Jacoby,  S. :  Gonorrhoebehandl.  mit  Stauungshyp.    Berl.  klin. 

Wchnschrft.,  1906,  No.  26. 
Jerusalem :  Biersche  Stau-  u.  Saugbehandlung  i.  d.  Kassen- 

praxis.     Wien.  klin.  Rundschau,  1906,  No.  23. 
Jordine :  Bier's  Venous  Cong.  Treatment  of  Tbc.  Arthritis. 

Maritime  Med.  News,  Halifax,  1906,  xviii. 
Joseph,   Eugen :  Ueb.    d.    friihzeitige   und   prophylaktische 

Wirkung  der  Stauungshyperamie  auf  inficierte  Wunden. 

Miinch.  med.  Wchnschrft.,  1906,  Nos.  38,  39. 
Joseph :  Dtsch.  Ztschrft.  f.  Chir.,  vol.  87,  p.  425. 
Kaefer :  Zur    Behandlung    acut.    eitriger    Entziindung    mit 

Stauungshyperamie.     Cntrlbltt.  f.  Chir.,  1906,  Nos.  9,  10; 

and  Khirurgia  Mosk,  1906,  xix,  403. 


LITERATURE.  241 

Kirchhoff :  Uel).  Behandl.  v.  Tl)c.  nach  Bier.     Dissertation, 

-Miinchen.  1906. 
Klapp  :  Behandl.  acut.  Entziindungen  mit  Stauungshyperam. 

Ztschrft.  f.  arztl.  F(n-t])ildung.  1906.  Xo.  8. 
Klapp:  Die  8augl)ehandlung.     Berl.  Klinik,  Febr.,  1906. 
Klapp  :  Behandl.  chir.  The.  niit  d.  Schropfverfahren.     Arch. 

f.  klin.  Chir.,  Ixxx,  1,  1906. 
Koch,  Carl :  Biersche  Behandlung  acut.  f]ntzundungen  mit 

Stauungshyperamie.      Miinch.    med.   Wchnschrft.,    1906, 

Xo.  12,  p.  580. 
Konig :  Uelj.    Stauungsbeh.    d.    Epididymitis    gonorrhoica. 

Med.  Klin.,  1906,  Xo.  24. 
Konig :  Die    Tbc.    d.    menschl.    Gelenk.     .     .     Hirschwald, 

Berlin,  1906. 
Kopetzky  :  The  Treatment  of  Acute  Otitis.     Med.  Purul.  and 

Mastoidit.  by  Cleans  of   Artific.  Hyp.     X'ew  York  Med. 

Joiu-n.,  1906.  Ixxxiii,  p.  1232. 
Kopetzky :  Arch.  f.  Otology,  1906,  vol.  35,  Xo.  4. 
Kozlowski :  Cntrlbltt.  f.  Chir.,  1906,  p.  83. 
Kuhn,  E. :  Lungensaugma.ske  zur  Erzeugung  v.  Stauungshyp. 

in  d.  Lungen.     Dtsch.  militarztl.  Ztg.,  xxxv,  5,  1906. 
Kuhn  :  Dtsch.  med.  Wchnschrft.,  1906,  Xo.  37. 
Laccetti :  Duo  casi  di  flemmone.     Gazetta  internazionale  d. 

Medicina,  1906,  Xo.  88. 
Lammerhirt :  Behandl.   mit  Stauungshyp.   nach    Bier  in   d. 

Hand  d.  prakt.  Arztes.     Med.  Klin.,  1906,  Xo.  15. 
Lanz :  Ueb.  Biersche  Stauungstherap.     Miinch.  med.  Wchn- 
schrft., 1906,  Xo.  26. 
Le  Fort :  Les  methodes  de  Bier  telles  qu'elles  sont  appliquees 

a  la  clinique  de  Bonn.     Echo  med.  du  nord.  Lille,  1906, 

x,  p.  521. 
Leo :   Ueb.   Hyperamiebehandl.    d.   Lungentbc.      Berl.   klin. 

Wchnschrft.,  1906,  Xo.  27. 
•  16 


242  bier's  hyperemic  treatment. 

Leuwer  :  Ein  neuer  Xasensauger.     Dtsch.  med.  Wchnschrft., 

1906.  No.  10. 
Lexer:  Z.  Stauungshvp.  1).  acut.  Entzi'indungen.     Cntrll)ltt. 

f.  Chir.,  1906,  Nos.  18-20. 
Lexer :  35.  Dtsch.  Chir.  Cong.     Ibid.,  No.  28. 
Lexer:  Miinch.  med.  Wchnschrft.,  1906,  No.  14. 
Leyden,  v.,  u.  Lazarus :  Ueb.  d.  Behandlung  d.  Gelenkent- 

zi'indung  mit  d.  Bierschen  Stauung.     v.  Leuthold  Gedenk- 

schrift,  vol.  i. 
van  Lier  :  Stauungstherapie.    Gesellschaft  zur  Beforderung  d. 

Naturwiss.  u.  Med.   Amsterdam.     Miinch.  med.  Wchn- 
schrft., 1906,  No.  26. 
Lindenstein  :  Erfahrungen  mit  d.  Bierschen  Stauung.  Miinch. 

med.  Woch.,  1906,  No.  38. 
Lessen :    Biersche   Stauungsl^eh.  bei   Sehnenscheiden  Phleg- 

monen.     Med.  Khn.,  1906,  p.  650. 
Manninger  :  Heikmg  local.  Infect,  mit  Hyperaemie.     Wiirzb. 

Abhandl.  a.  d.  Gebiet  d.  prakt.  Med.,  1906,  vi,  p.  155. 
Maragliano  :  Ricerche  sperimentali  sulla  stasi  alia  Bier.  Gazz. 

d'osp.  Milano,  1906,  xxvii,  849. 
Martin :  Technik  d.   Saugbehandl.   v.    Nasenleiden.     Dtsch. 

med.  Wchnschrft.,  1906,  No.  52. 
Matthes  :  Lehrbuch  d.  klin.  Hydrotherap.     Jena,  1906,  p.  31. 
Mautner :  Behandl.    d.    Sauglingsfurunkulose    mittels    Bier- 

Klapp's  Stauung.     Allg.  Wien.  Med.  Ztg.,  1906,  li,  p.  273. 
Mayer,  L. :  \"aleur  curative  de  I'hyper^mie.     Journ.  med.  d. 

Brux,  1906,  xi,  p.  753. 
Mcllhenny  :  Bier's  \^acuum  Hyperaemia  in  the  Treatment  of 
.  Carbuncle.     New  Orl.  Med.  and  Surg.  Journ.,  1906-07, 

lix,  29. 
Mindes :  Technik  des  Bierschen  Verfahrens.     Miinch.  med. 

Wchnschrft.,  1906,  No.  6,  p.  263.    Cntrlbltt.  f.  Chir.,  1906, 

3  and  4. 


LITERATURE.  243 

Mislowitzer  :  Erfahruiigen  niit  d.   Bierschen  HehaiKllung  cl. 

Mastitis.     Med.  Klin.,  1906,  p.  887. 
Moll :  Technik   d.    J^ierschen    Hyperaniie   f.    d.    l^ehaudl.    d. 

Mastitis.     Wien.  klin.  Wuch.,  19(36,  No.  17. 
Moore  :  Deep  Capillary  Stagnation.     ^led.  Standard,  Chicago, 

1906,  xxix,  p.  409. 
Moschcowitz,    Eli:    A   New   Method  of  Treatment  of  Acne. 

N.  Y.  Medical  Record,  1906,  vol.  Ixix,  p.  60. 
Muller  :  Anwendung  d.  Bierschen  Staining  gegen  Heuschnup- 

fen.     Therap.  Monatshelfe,  1906,  p.  444. 
Neu  :  Anwendung  kiinstlich  erzeugter  venoser  Hyperaniie  d. 

Gehirns  bei  Geisteskranken.    Psychiatr.-neurolog.  AVoch., 

1906,  No.  15. 
Nordmann :  Erfahrungen   iib.    Staunngshyp.    b.    acut.    Ent- 

ziindungen.     Med.  Klinik,  1906,  No.  29. 
Nyrop  :  Licit  om  Stasehyperemi.  Ugesk.  f.  Laeger.  Kobenh., 

1906,  5.  R.,  p.  529. 
Onodi :  Ueb.  d.  Anwendung  d.  Bierschen  Stauung  b.  krkhtn. 

d.  oberen  Luftwege.     Pest,    med.-chir.   Presse,   Budap., 

1906,  xlii,  310. 
Palmer :  The   Bier  Congestion  Treatment.     Chicago   Clinic, 

1906,  xix,  77. 
Perthes  :  Chir.  Congress,  1906. 
Pezold  :  Furunkelbeh.  mittels  Bierscher  Saugapparate.  Dtsch. 

militararztl.  Ztschr.,  1906,  xxxv. 
Pfann  :  Behandl.  d.  subacut  u.  acut.  Infection  durch  Steiger- 

ung  d.  Hyperamie.     Pest.  med.  chir.  Pr.,  1906,  xviii,  947. 
Pogne  :   Report  of  5  Cases   of   Localized  Infection  Treated 

by  Bier's  Method.     Denver  Med.  Times,  1906-07,  xxvi, 

447. 
Polini :  Stasi  alia  Bier.     Gazz.  internazionale  di  Nap.,  1906, 

ix. 
Politzer  u.  Isemer :  Arch.  f.  Ohrenhlkde.,  1906,  Ixix,  1,  2. 


244  bier's  hyperemic  treatment. 

Polyak :  The  Employment  of  the  Graduated  Hyperemia  of 

Bier  in  Diseases  of  the  Upper  Air-passages.     Oroosi  hetil. 

Budapest,  1906,  i,  303. 
Ranzi :  Ueb.  d.  Behandl.  acut.  Entziindungen  mit  Stauungs- 

hyp.     Wien.  klin.  Woch.,  1906,  No.  4. 
Ranzi :  35.  Chir.  Congr.     Cntrlbltt.  f.  Chir.,  1906. 
Rattner :  Das  Biersche  Verfahren.     AUg.  med.  Central  Zeit- 

ung,  1906,  Ixxv,  749. 
Raudnitz :  Zwei    neue    Saugapparate.     Prag.    med.    Woch., 

1906,  No.  34. 
Renner :    Ueb.    Biersche     Stauungsh3'p.     bei     Augenkrkht. 

Miinch.  med.  Wchnschrft.,  1906,  No.  2,  p.  62. 
Rethi :  Die    Ozaena    u.    d.    Stauungstherapie.     Wien.    klin. 

Wochenschrift,  xix,  39,  1906. 
Risquez  :  El  metode  de  Bier.     Rev.  espec.  med.  Madrid,  1906, 

ix,  449. 
Ritter :  Die  Verwertung  d.  Saugapparates  zur  Diagnose  bei 

bosartigen  Geschwiilsten.    Dtsch.  med.  Wchnschrft.,  1906, 

Nos.  29-31. 
Robbers  :  Pneumoniekokken  oder  Stauungsgangran.     Dtsch. 

med.  Woch.,  1906,  No.  16. 
Rubritius :  Behandl.    acut.    Entziindungen    mit    Stauungs- 

hyperamie.     Beitr.  z.  klin.  Chir.,  xlviii,  2,  1906. 
Savelle :  L'iperemia    venosa     aitificiale     nelle     terapeutica 

chirurgica.     Pratica  d.  med.  Napoli,  1906-07,  vii,  193. 
Scheibe :  Ueb.    d.   therap.    Verhalten  b.    acut   Mittelohreit- 

erungen  mit  Beriicksichtigung  ihrer  verschied.  Aetiologie. 
Scheuer :  Was  soil  d.  prakt.  Arzt  v.  d.  Behandl.  mit  Stau- 

ungshyp.  wissen?     Aerztl.  Prax.,  1906,  xix,  193. 

Miinch.  med.  Wchnschrft.,  1906,  No.  21. 
Schmieden :  Ein  neuer  Apparat  zur  Hyperamie  Behandlung 

d.  Kopfes.     Miinch.  med.  Woch.,  1906,  No.  31. 
Schonberg :  Dtsch.  med.  Wchnschrft.,  1906,  No.  43. 


LITERATURE.  245 

Schbngut :  Therap.  d.  Otitis  externa  circumscripta.     Utsch. 

ined.  Wchnsclirft.,  1906,  No.  43. 
Schwarze :  Klin.    Krfahrunoen   niit    d.    Stauungsliyp.    1).    d. 

l^ehandi.  acut.  Otitis.     Miinch.  med.  Wcliuschrft.,  1906, 

Xo.  :u. 
Sondermann :  Zur    Saugtherapie    l^ei     Nasenerkrankungen. 

Miincli.  nied.  Wchnsclirft.,  1906,  No.  45. 
Stahr :  Ueb.  d.  Blutbefund  1).  d.  Bierschen  Stauungstherapie. 

Wien.  klin.  Woch.,  1906,  No.  9. 
Stenger  :  Biersche  Stauung  b.  acut.Ohreiterung.    Dtsch.  med. 

Wchnschrft.,  1906,  No.  6- 
Stich  :  Congr.  f.  Chir.,  1906. 
Strauss  :  Die  aiitomatische  Saugspritze  als  Saiigapparat  fiir 

Biersche    Stauung.     Miinch.     med.     Wchnschrft.,    1906, 

p.  656. 
Thierry :   Licecenje  Bierovom  hyperaemijom  Lice  viestnik. 

u.  Zugrebn,  1906,  xxviii. 
Thole  :  Chir.  Congress,  1906. 
Thorbeke  :  Behandl.  d.  puerperal.  Mastitis  mit  Stauungsliyp. 

Med.  Klin.,  1906,  Nos.  37,  38. 
Tomaschewski :  Behandl.  acut.  infectioser  chir.  Erkrankung. 

mit    Stauungshyp.     Russky    Wratsch,     1906,    No.     12; 

Miinch.  med.  Woch.,   1906,  No.  37;    Cntrlbltt.  f.  Chir., 

1906,  No.  27. 
Trancn-Rainer  :  Die  Biersche  Methode  i.  d.  Gynak.     Revista 

stiintelor     med.,     1906,     July-August.     Miinch.     med. 

Wchnschrft.,  1906,  p.  2408. 
Turan  :  Das  Biersche  Verfahren  in  intrauteriner  Anwendung. 

Cntrlbltt.  f.  Gyn.,  1906,  xxx,  28. 
Turan  :  Versuch  mit  clem  Bierschen  Verf.  bei  Endometritis. 

Cntrlbltt.  f.  Gyniik.,  1906,  No.  12. 
Ullmann :  Ueb.  Stauungs  und  Saugtherap.  b.  einigen  Affect. 

d.  Haut.     Berl.  klin.  Woch.,  1906,  No.  19. 


246  bier's  hyperemic  treatment. 

Viannay :  La    methode    hyperhcmique    de    Bier.      Province 

medicale,  1906,  No.  34. 
Vander  Veer :  Report  of  Cases  Treated  by  a  ^lodified  Bier- 

Klapp  Method  of  Passive  Hyp.    Albany  Med.  Ann.,  1906, 

xxvii,  836. 
Venus  :  Zur  Orientirung  d.  prakt.  Arztes  lib.  d.  Anwendung  d. 

Stauungshyp.    nach    Bier.     Med.    Blatter.    Wien,    1906, 

xxix,  403. 
Walter :  Anwendung    d.    Bierschen    Saugverfahrens    in    d. 

Tierheilkunde.      Berl.    tieriirztl.    Wchnschrft.,    1906,    p. 

891. 
Weecke :  Ueb.   Biersche  Stauung  u.  ihre  Erfolge.   Arch.  f. 

phys.  Med.  iind  med.  Technologie,  1906,  i,  129. 
Wessel :  Om  den  Bier'sche  Stasehyperemi  behandkmg  og  dens 

Anvendelse.     .     .     Hospitals  tidende,  1906,  Nos.  30-33. 
Wessely :  Verh.  d.  Berl.  med.  Ges.    Berl.  klin.  Woch.,  1906, 

No.  51. 
Wiener  :  Art  if.  Hyperemia  in  Surgery.     Illinois  Med.  Journ., 

1906,  ix,  241. 
Wolff-Eisner :   D.  Biersche  Stauungshyp.  vom  Standpunkt 

d.  Endotoxinlehre.     Miinch.  med.  Wchnschrft.,  1906,  p. 

1102. 
Wyman :  Passive  Hyperemia  in  Treatment  of  Tbc.  Synovitis 

of   Knee   and   of   Infected   Contusions.     Virginia   Med. 

Semi-monthly,  1906-07,  xi,  p.  359. 
Zimmermann  :  Gynladasok  gyogyitasa  pangasos 

AUatorvosi  lapok.  Budapest,  1906,  xxix,  p.  530. 

1907. 
Abrand :  Uonnees    pratiques    de    la    methode    d'hyperemie. 

Clinique.  Par.  1907,  ii,  201. 
Albeker :  Bier's  stasis.     Gyogyaszat.    Budapest,  1907,  xlvii. 


LITKRATURE.  247 

Auffret :  De  rutili.sation  par  les  praticien.s  cle  la  methocle  de 

Bier.     Journ.  cl.  med.  de  Paris.  1907.  xix.  p.  291. 
Axamit :  \'er<uche  iib.  Stauungshyp.   am  Kaninchen.     Wien. 

klin.  Woch.,  xx,  34,  1907. 
Ballin  :  Hyperemia   as  a  Treatment  of  Acute  and  Chronic 

Inflanmi.  Diseases.    Detroit.Med.  Journ.,  1907,  vii,  45-54. 
Bango  :  El  tratiamento  de  liier.     Rev.  de  med.  y  cirurg.  de 

la  Habana,  1907,  xii,  179. 
Barcroft :  On  Bier's  Treatment  of  Acute  Inflamm.  Conditions 

by  Hyperemia.    Edinb.  Med.  Jourii.,  1907,  n.  s.,  xxi,  512. 
Bart :  Treatment  of  Acute  Suppuration  by  Static  Hyperemia. 

Voyenno  med.  J.  St.  Petersb.,  1907,  ccxix. 
Beckman :  Bier's   Cong.    Therapy.     St.    Paul    Med.    Journ., 

1907,  iv,  762. 
Bendig  :  Ueb.  d.  Wirkung  d.  Saugstauung  nach  Bier.     Kon- 

igsberg,  1907,  8°,  23  pp. 
Berry  :  The  Present  Status  of  Bier's  Method  of  Treatment  by 

Congestive  Hyp.     Alb.  Med.  Ann.,  1907,  xxviii,  p.  274. 
Besson  :  Technique  le  la  methode  de  Bier.     Journ.  d.  sc.  med. 

de  Lille.  1907,  ii,  433. 
Bier  :  Hyperamie  als  Heilmittel.     6.  Auflage.  1907,  Leipzig, 

Vogel. 
Bier :  L'hyperemie  et   .son   action   therapeutique.     Ouvrage 

traduit  par  Machard.     Geneve,  1907,  432  pp.,  8°. 
Bonheim :  Behandl.   acut.   Entziindung  mit  Hyperaemie  n. 

Bier.     Mitteilungen   a.  d.  Hamb.   Staatskrankenanstalt, 

vii.  12,  1907. 
Borbely  :  The  Artificial  Hyp.  of  Bier.     Gy6g}-aszat,  Budapest, 

xlvii,  1907,  p.  432. 
Bouman  :  Artificial  Congest.  Hyperaemia  after  Bier.     Journ. 

Minn.  Med.  Assoc,  xxvii,  1907,  p.  284. 
Burckhart :  Hyperemia  as  a  Remedy.    Indiana  Med.  Journ., 

1907-08,  xxvi,  12. 


248  bier's  hyperemic  treatment. 

Burn-Murdoch  :  Edinburgh  Med.-Chir.  Society.   Lancet,  1907, 

26,  i. 
Canel :  La  methotle  de  Bier.    Arch,  de  med.  et  pharm.  miUt. 

Par.,  1907,  xUx,  13-24. 
Corner :  The  Treatment  of  Inflamm.  by  Producing  Passive 

Cong.     CUn.  Journ.,  London,  1907,  xxx,  94. 
Decref :  Hiperemia  activa  por  et   aire  caUente  come  medio 

terapeutico.    An.  r.  acad.  de  med.  Madrid,  1907,  xxvii,  79. 
Delageniere  :  Contrib.  a  I'etude  de  la  stase  hyperhemique,  ou 

methode  de  Bier.     Journ.  d.  med.  et  chir.  prat.,  Ixxviii, 

1907. 
Deutschlander :  Hyperamiebehandl.   d.   Knochen    und    Ge- 

lenktbc.     Miinch.  med.  Woch.,  1907,  p.  721, 
Duclaux :  Indications  et  resultats  de  la  methode  de  Bier. 

Progres  med..  Par.,  1907,  xxiii,  465. 
Esch  :  Antiphlogose,  Hyperamiebehandl.  u.  feuchter  Verband. 

Med.  Klin.,  1907,  p.  118. 
Eschweiler :  Behandl.  d.  Mastoiditis  mit  Stauungshyp.  nach 

Bier.     Arch.  f.  Ohrenheilkunde,  1907,  vol.  71,  p.  85. 
Feleki:  Artific.  Plethora.     Urologia,  Budapest,  1907,  1-11.  ' 
Fichera :  L'iperemia  da  stasi  nelle  infezioni  acuta.     Policlin. 

Rom.,  1907,  xiv. 
Flett :  Treatment  of  Some  Inflammatory  Conditions  by  Bier's 

Method.     Practitioner,  Lond.,  1907,  Ixxxix,  517, 
Fraenkel :  Ueb.    d.    Biersche    Behandl.    mit    Stauung    und 

Saugapparat.     Allgem.  Wien.  med.  Ztg.,  1907,  25, 
Frose :  Ein  weiterer  Beitrag  z,  d,  Erfahrungen  bei  der  klin, 

Behandl,  v,  Mittelohreiterungen  mit  Stauungshyperamie 

nach  Bier,     Arch,  f,  Ohrenheilkunde,  1907,  vol,  71,  p.  1. 
Gerson :  Eine  Combination  v.  Saugglas  und  Messer,     Med, 

Klin.,  1907,  iii,  261. 
Grammenitzki :  Z.  Behandl.   mit  Stauungshyp.   nach  Bier. 

AUg.  med.  Cntralztg,,  1907,  Ixxvi,  p.  65. 


LITERATURE.  249 

Gruber   und    Futaki :  Ueb.    d.    Hesistenz   gegen  ^lilzbmnd. 

Miinch.  med.  Woch.,  1907,  No.  6. 
Hartmann :  Behandl.  von  12.  Mastitideii  mit   Saugapparat. 

^liinch.  med.  Woch.,  liv,  6,  1907. 
Heinsius    u.    Lissauer :  Erfahrungen    lib.    Brustdri'isenent- 

ziindung  u.  Behandl.  mit  Bier's  Stauung.     Dtsch.  med. 

Woch.,  1907,  xxxiii,  2132. 
Henriksen  :  Hyperaemi  som  laegemiddel,  Bier's  Stasebe-hand- 

ling.  Tidsslvr.  f.  d.  Norske  Laegefor,  1907,  xxvii,  285. 
Hilgenreiner :  Experim.  Unters.  iib.  d.  Einfluss  d.  Stauungs- 

hyp.    auf    Heihmg    d.    Knochenl:)ruche.     Beitr.    z.    kUn. 

Chir.,  hv,  3,  1907. 
Honigmann :  Uel).    d.    Wirkung   d.    Bierschen   Stammg   im 

Allgem.  Intern.  Cntrlbltt.  f.  Ohrenheilk.,  1907-08,  vi,  1. 
Honigmann  u.  Schaffer :  Exper.  Unters.  iib.  d.  Wirkung  d. 

Bierschen  Stauung  auf  d.  Entziindungsvorgang.     Miinch. 

med.  Woch.,  1907,  No.  36. 
Hoppe  :  Passive  Hyperaem.  n.   Bier  i.  d.  Therap.  d.  Augen- 

krkht.     Med.  Klin.,  1907,  iii,  5,  p.  112. 
Jaworski :  Treatment  of  Inflamm.  of  the  Cervix  by  Bier's 

Method.     Now.  Cek.  Poznon,  1907,  xix,  613. 
Jerusalem :  Neuere  Indicationen  fiir  Biersche  Saugbehand- 

lung.  Miinch.  med.  Wchnschrft.,  1907,  No.  51,  p.  2554. 
Klapp  :  Ueb.  Luftmassage.  Miinch.  med.  Wchnschrft.,  1907,  1. 
Klemperer :  Zur  Behandl.  d.  acut.  Gelenkrheuma.     Therap. 

d.  Gegenwart,  1907,  N.  F.,  ix,  6. 
Koda :  The  Treatment  of  Bier  by  Blood  Stasis  in  Otology. 

Tokyo  Jji-Shinshi,  1907,  2967. 
Krbmer :  Das    Biersche    Stauungsverf.     i.     d.     Gynakolog. 

Cntrlbltt.  f.  Gynak.,  1906,  No.  4. 
Kuhne :   Anwendung    d.    Bier-Klappschen    Saugapparat.    z. 

Orthopad.  Zwecken.     Monatsschrft.  f.  Unfallheilk.,  1907, 

xiv.  104. 


250  bier's  hypere:\iic  treatment. 

Kuhn  :  Weitere  Erfahrungen  niit   d.    Hyperamiebehandl.  d_ 

Lungen  mit  d.  Lungensaugmaske.     Miinch.  med.  Woch., 

1907,  p.  782. 
Kushtaloff  :  liier's  Arterial  Hj-periemia  in  Country  Practice. 

Liek.  Pons.  Voronezh.,  1907,  119. 
Ledent :  La  methode  de  Bier  et  les  instituts  de  mechano- 

therap.     Ann.  de  med.  phys.,  1907,  v,  p.  219. 
Lemire  et  Ducrotoy :  Note  sur  quelques  applications  de  la 

methode  de  Bier.     Rev.  d.  med.  vet.  Par.,  1907,  Ixxxiv, 

757. 
Leutert :  Biersche    Stauung    i.    d.    Otologie.     Dtsch.    med. 

Woch.,  1907,  No.  31. 
Leuwer  :  Zur  Saugbehandl.  d.  acut.  IMittelohreiterung.     ]\Ied. 

Klin.,  1907,  No.  41,  p.  1281. 
Lewith :   Ueb.   Stauungsbehandl    bei   gynak.  Affect.     Wien. 

med.  Wchnschrft.,  1907,  No.  36;    and  Med.  Klin.,  1907, 

p.  1471. 
Lichtenstein  :   Einiges  z.  Bierschen  Stauung.     AUgem.  med. 

Cntrl.  Ztg.,  1907,  p.  129. 
Liibbert :     Zur   Ausfiihrung   d.    Hyperamie    Behandlung   d. 

Antiphlogistin.     Therap.  Monatsh.,  1907,  No.  11. 
Lumniczer :     Hyperam    als    Heilmittel    nach    Bier.     Pest. 

med.  chir.  Presse,  1907,  xHii,  609. 
Makara :    Die   Biersche   passive   hyperamisirende   Behandl. 

i.  d.  Chir.     Pest.  med.  chir.  Presse,  1907,  xliii,  pp.  872, 

893,  957. 
Maire :    Les  m^thodes  de   Bier.     Centre,   med.   et  pharm., 

1907-08,  33. 
Mcintosh  :  Stasis  Hyperaem.  or  the  Bier  Treatment  of  Acute 

Inflamm.     Amer.  Med.,  Phila.,  1907,  n.  s.  ii,  632. 
McLennan :     Treatment    of    Microbic    Invasions    by    Bier's 

Hj'persemia.     Practitioner,  1907,  p.  507. 


LITERATURE.  251 

Meyer,  W.  :   Bier's  Treatment  in  Chronic  and  Acute  Surgical 

Infectious    Diseases.     Jour.   Am.   Med.   Assoc,  Chicago, 

1907.  p.  560. 
Meyer,  W.  :    Kuhn's  Lung  Suction  Mask  for  the  Hypenemic 

Treatment  of  Pulm.  The.     X.  Y.  Med.  Rec,  Nov.  9,  1907. 
Moritz  :   Zur  Behandl.  d.  Haut-und  Geschlechstkrkhtn.  mit 

Bier's  Stauung.     Wien.  med.  Presse,  1907,  xlviii,  19. 
Muck  :    Aphoristische  Mitteil.  ill),  d.  Einfiuss  d.  v.  Gehorgang 

aus    (lurch    Saugwirkung    hervorgerufenen    Stauungshy- 

peraemie.     .     .     .     ^liinch.   med.   Wchnschrft..  1907,  p. 

41.3. 
Muck  :    Ein  geheilter.  mit  Stauungshyp.  l^ehandeker  Fall  v. 

Ixlstgr.  Mittelohrtbc.  Ztschr.  f.  Ohrenhlkde.,  1907,  p.  132. 
Murdoch  :    Notes  on  Some  Cases  Treated  by  Bier's  Method. 

Scot.  Med.  and  Surg.  Journ.,  Edinb.,  1907,  xx,  133. 
Nenadovics  :  Behandl.  nach  Bier  i.  d.  Gynakolog.  Gynakolog. 

Rundschau,  1907,  Xo.  9. 
Neu :    Die    Circulationsverhaltnisse    im   Gehirn  nach  kiinst- 

licher  Hyperaemie.     X'eurolog.  Cntrlbltt.,  1907. 
Nobili :  Sull  azione  terapeutica  della  stasi  alia  Bier.     Pratica 

d.  med.,  1907-08,  viii,  225. 
Oppenheim :    Behandl.    d.  Haul-  u.    Geschlechtskrkht.    mit 

Bierscher  Stauung.     Wien.  med.  Presse,  1907,  X"o.  19. 
Pal :    Arterielle   Stauung.  79.  Vers,  dtsch.   N^aturforscher  u. 

Arzte.     Miinch.  med.  Woch.,  1907,  No.  40. 
Paul :   Beitrag  z.  Bierschen  Stauung.     Cntrlbltt.  f.  Gynakol., 

1907,  Nos.  23,  24. 
Perl :  Behandl.  mit  Stauung  u.  Saughyperaemie  i.  d.  allgem. 

Praxis.     Berl.  Klinik,  1907,  xix,  224. 
Petersen  :  Some  Notes  on  Bier's  Passive  Hypersemia.     South 

Afric.  Med.  Rec,  1907,  v,  p.  307. 
Pollak :   Beitr.  z.  activ.  Bierschen  Hyperaemie  i.  d.  Gynakol. 

Wien.  klin.  Woch.,  1907,  No.  41. 


252  bier's  hyperemic  treatment. 

Pospieloff :    Behandl.  verschied.  Krkhtn.  d.  Haut,  mit  pass. 

Hyperaem.    n.    Bier.     Med.    Obozr.    Mosk.,    1907,  Ixvii, 

53-60. 
Putzler :    Beitr.   zur    Staiiungsbehandlung  mit  kiinstl.   Hy- 
peraem.    Arch.  f.  Dermatol,  u.  Syph.,  1907,  Ixxxv,  37. 
Reclus :   De  la  methode  de  Bier.     Progres  mM.,  1907,  3.  S., 

xxiii,  p.  890. 
Riedl :   Erfahrungen  und  \^ersuche  mit  dem  Stau-  und  Saug- 

verfahren.     Wien.  klin.  Wchnschrft.,  1907,  No.  8. 
Ritter :     Behandl.    inoperabler    Tumoren    mit    kiinstlicher 

Hyperamie.     Miinch.  med.  Woch.,  1907,  p.  2125. 
Ritter  :  Verwertung  d.  Saugapparate  zur  Diagnose  bosartiger 

Geschwiilste.     Dtsch.  med.  Wchnschrft.,  xxxiii,  31,  1907. 
Roberts :  Continuous  Passive  Hyperemia  in  Delayed  Union 

of  Fractures.     Tr.  Am.  Surg.  Assoc,  Phila.,  1907,  xxv,  33. 
Robins :   Bier's  Treatment  with  Hyperaem.     Old  Dominion 

Journ.  Med.  and  Surg.,  1907-08,  vi,  p.  392. 
Robins :    Virginia  Semi-monthly,   Richmond,    1907-08,   xii, 

p.  204. 
Rbpke :    Active   Hyperaem.   in    Behandlung   arteriosclerot. 

Gangran.     Miinch.  med.  Woch.,  1907,  p.  666. 
Rosenberger :    Ueb.  d.  Verlauf  d.  acuten  Entziindung  mit 

u.  ohne  Stauungshyperaem.     Ziegler's  Beitrag.  z.  pathol. 

Anat.,  1907,  vol.  41,  No.  2. 
Rotter :    The  Bier  Treatment  in  Gynecology'.     Orvosi  hetil. 

Budap.,  1907,  li,  p.  272. 
Salkindsohn  :  Ein  neuer  Apparat  z.  Therap.  mittels  negativ. 

Luftdrucks  nach  Bier-Klapp.     Cntrlbltt.  f.  Chir.,  1907, 

xxxiv,  20-22. 
Sauer :    Mastitis   und   Biersche   Stauung.     Erlangen,    1907, 

.   8°,  47  pp. 
Schade  :  Wirkung  d.  Priessnitz  Umschlage  b.  d.  Entziindung. 

Miinch.  med.  Woch.,  1907,  No.  18. 


LITERATURE.  253 

Schaffer :    Einfluss   neuerer  therap.   Massnahmen   aiif   Ent- 

zundiing.  Experim.  Enters,  lib.  heisse  L^mschlage.     Ther- 

mophor Stuttgart,  1907.    Ferd.  Enke.    gr.  Svo, 

vii  and  237  pp. 
Schattmann  :    Zur  Saugijehandlung  der  Cervix   gonorrhoe. 

Arch.  f.  Dermatol,  u.  Syphilis,  1907,  p.  105. 
Schlaeger  :    Eeb.  d.  Stauungsbehandlung  bei  Seekrankheit. 

:\liinch.  med.  AVoch.,  1907,  No.  28. 
Schlatter :    \Jeh.  d.    Biersche   Hyperamiebehandlung.     Corr. 

J^ltt.  f.  Schweizer  Arzte,  1907,  xxxvii,  13. 
Schmidt,    C.  :     Bedeutung    d.    prophylaktischen    I^ierschen 

Stauung  i.  d.  Unfallheilkunde.     Alonatsh.  f.  Unfallheilk., 

1907,  Xo.  4. 
Schmieden  :  The  Theory  and  Application  of  the  Hyperaemic 

Treatment  of  Bier.     Folia,  therap.,  1907. 
Schmieden:   Technique  of  Treatment  by  Hypersemia  (Bier). 

Translation  by  C.  G.  Levison.     Journ.  of  Balneol.  and 

Climatology^  Oct.,  1907,  London. 
Schmieden :    The   Treatment   of   Surgical   Tul)erculosis   by 

Hyperemia  (Bier).     N.  Y.  Med.  Rec,  Aug.  17,  1907. 
Schmieden  :   Instruction  pour  le  traitement  par  I'hyperemie. 

Traduit    par   Mme.    Fortaul.     Par.,   1907,  46   pp.,    Svo. 

Avec.  preface  de  Tuffier. 
Schmieden  :   Anleitung  z.  Hyperamie-Behandlung  nach  Bier. 

Reichsmedicinalkalender,  1907. 
Schultze,  K.  :  De  la  methode  de  Bier.     Progres  Med.,  1907, 

No.  51. 
Seelig :     Stasis    Hypersemia.     Interstate    Med.    Journ.,    St. 

Louis,  1907,  p.  988. 
Sick  :    Grenzgeb.  f.  Biersche  Stauung.     Dtsch.  med.  Wchn- 

schrft.,  1907,  No.  25. 
Stein :     Anwendung    Bierscher    Stauung    bei    Verbrennung. 

Dtsch.  med.  Wchnschrft.,  1907,  No.  49. 


254  bier's  hypp:rp:.mic  treatment. 

Steinitz :     Ueb.    d.    Behandl.    d.    acut.    Gelenkrheuma.    mit 

Stauungshyp.     Ztschft.  f.  klin.  Med.,  Ixiv,  1907,  p.  125. 
Stern :    Behandl.  d.   Epididymitis    u.  d.   Bubonen    mit   Hy- 

peramie.     Mimch.  med.  Woch.,  1907,  p.  2385. 
Stern  :  Verh.  d.  Berl.  Kongresses,  1907,  ii,  p.  488. 
Stiassny :   Beit  rag    z.  Prophylaxe    u.  Therapie  d.   Mastitis. 

Gynak.  Rundschau,  1907,  p.  5. 
Stolzenburg  :   Uel).  d.  mit  d.  Kuhnschen  Lungensaugmaske 

i.  d.  Heilstatte  gemachten  Erfahrungen.     Miinch.  med. 

Woch.,  1907,  p.  781. 
Szalai :    The  Hyperaemic  Treat m.  in  General   Medical  Prac- 
tice.    On-osi.  hetil.,  1907,  pp.  257,  277,  294,  312. 
Tautzscher :   Ueb.  Biersche  Stauung.     Petersb.  med.  Wchn- 

schrft.,  1907,  p.  341. 
Tarantini :    Experiment.  \'ersuche   iib.  d.   Mechanismus  d. 

Wirkung  d.  Bierschen  Stauung,     II  policlinico,  Oct.,  1907. 
Tomita,    Chutaro :     Ueb.    d.    Hyperaemie   der   Haut   nach 

Esmach's  Bkitleere.     Arch.  f.  Physiol.,  cxvi,  5  and  6,  p. 

299,  1907. . 
Tuffier  :  Therap.  d.  inflamm.  des  parties  molles  par  la  methode 

de  Bier.     Rev.  gen.  de  clin.  et  de  therap.,  1907,  xxi,  833. 
Tuffier:    L'hyperemie  veineuse  dans  les  infectious  aigues  de?* 

membres.     Journ.  de  physiotherapie,  1907,  p.  112. 
Tuffier  :  Bull,  et  mem.  Soc.  de  Chir.,  1907,  xxxiii,  169. 
Vander  Veer :   The  Use  of  the  Bier-Klapp  Methods  in  In- 
fections of  Children.     Pediatrics,  N.  Y.,  1907,  xix. 
Viannay :    La  methode  de  Bier.     Med.  d.  accid.  du  travail. 

Par.,  1907,  v,  pp.  33-58. 
Villemin  :  La  methode  de  Bier  par  la  stase  veineuse.     Journ. 

d.  med.  d.  Paris,  1907,  p.  65. 
Vogel :  Miinch.  med.  Wchnschrft.,  1907,  No.  4. 
Vohsen  :  Beitrag  z.  Saug  und  Stautherap.  in  Ohr  und  oberen 

Luftwegen.     Miinch.  med.  Woch.,  1907,  No.  9. 


LITERATURE.  255 

Vorschiitz  :  Uie  Geniekstarre  und  ihre  Behancll.  mit  Bier.scher 

Stauung.     Miinch.  med.  Woch.,  1907,  No.  11. 
Walter:  Uel).  Biersche  Stauung  und  Saugapparat.     Verhandl. 

d.  pfillz.  Arzte,  1907,  xxiii,  5. 
Weil :     Bemerkungen    zur   Anwendung    d.    Saugtherap.    bei 

Naseneitemngen.     Wien.  med.  Wchnschrft.,  1907,  Ivii. 
Weinbrenner :   Die   Saugel^ehandl.    i.    cL    Gynak.    die   Saug- 

massage.     Munch,  med.  Woch.,  1907,  p.  1978. 
Wessely  :    Ueb.  d.  Wirkung  d.  Bierschen  Kopfstauimg  auf 

das    Auge    im  Tierexperiment.     Vers.  d.    ophthalmolog. 

Ges.,  1907,  143-153. 
Wolf  :    Artificial  Hypera?mia.     N.  Y.  Med.  Journ.,  1907,  p.  832. 
Wrede :      Stauungsbehandlung     acut     eitriger     Infectionen. 

Arch.  f.  khn.  Chir.,  1907,  vol.  84,  No.  3. 
Wulf  :    Die  kiinstliche  Hyperaemie  bei  acut   Entziindungen 

in  d.  Hand  d.  Arztes.     .Med.  Klinik,  1907,  p.  888. 
Zabel :   Biersche  Stauung  i.  d.  inn.   Medicin.     Med.  Woche., 

1907,  pp.  171,  185,  197,  209,  223,  234. 
Zacharias :     Behandl.    d.    Mastitis    mit    Bierscher   Stauung. 

Munch,  med.  Wchnschrft.,  1907,  No.  15. 

1908. 
Baetzner  :   Behandl.  d.  Arthritis  gonorrh.  d.  grossen  Gelenke 

mittels    Stauungshyp.     Dtsch.   Ztschrft.   f.    Chir.,    1908, 

xciii,  p.  46. 
Beaty  :    The  Indications  and  Technic  of  the   Hyperiemia  of 

Bier.     Journ.  Minn.  Med.  Assoc,  1908,  xxviii,  35. 
Bernheim :    Passive  Hypersemia    by  Means  of  Cupping    of 

Bier  and  Klapp.     Journ.  Am.  Med.  Assoc,  1908,  1,  p.  840. 
Binnie :    Hypersemia.     Journ.  of  Amer.   Med.    x\ssoc.,    1908, 

No.  26. 
Blecher :    Behandl.  acut.  entziindl.  Erkrkg.  mit  Hj-peramie. 

Dtsch.  Ztschrft.  f.  Chir.,  xciii,  1908,  p.  402. 


256  bier's  hyperemic  treatment. 

Braatz  :  SaugbehancU  d.  Bisses  wutkranker  Hunde.     ^liinch. 

med.  Woch.,  1908,  No.  28. 
Brooks  :  Hyperemic  Treatment  of  Acute  and  Chronic  Surgic. 

Affec.     Therap.  Gazette,  Detroit,  1908,  xxxii. 
Brown  :  Observ.  made  at  the  Bier  Clinic.     N.  Y.  Med.  Journ., 

1908,  Ixxxvii,  70. 
Carl,    W.  :     Biersche    Stauung   bei    Streptokokkeninfection. 

Virch.  Arch.,  vol.  194,  No.  1,  1908. 
Comolli :    La  cura  coll  iperemia  nella  clinica  del  prof.  Bier. 

Gazz.  d.  osp.,  1908,  xxix,  p.  333. 
Coste  :  Stauungshyp.  b.  acut.  Entziind.     Miinch.  med.  Woch., 

1908,  No.  12. 
Danielsen :   Ueb.  d.  Einfluss  d.  Warme  u.  Kaltebehandlung 

bei    Infectionen   d.    Peritoneums.     Centrlbltt.    f.    Chir., 

1908,  No.  5. 
Dauve  :    De  quelques  affections  traitees  par  la  methode  de 

Bier.     Belgique  med.,  1908,  xv,  171. 
Dessauer :  Die  Luftpumpe  i.  d.  arztl.  Praxis.  Therap.  Rund- 
schau, 1908,  ii,  p.  335. 
Dick :    Stauungsbehandl.  d.  Empyems.     Brit.   Med.  Journ.. 

1908,  2487. 
Durey  :  L'emploi  therapeut.  d.  I'hj'peremie  veineuse  par  stase 

et  d'hyperemie.     Journ.  de  med.  de  Par.,  1908,  xx,  p.  203. 
Fasiani :    Dell  influenza  della  stasi  alia  Bier  sullo  soiluppo 

del  tessuto   di  granulazione.     Giorn.   dell.   r.   accad.  d. 

med.  di  Torino,  1908,  Nos.  3-5. 
Fasiani :   Sull  emigrazione  dei  leucociti  nella  stasi  alia  Bier. 

Gior.  della  R.  accad.  d.  med.  di  Torino,  1908,  7-8. 
Felegyhkzi :   Stauung  bei  chir.  Tbc.  Orvosi  Hetil.,  1908,  Nos. 

38,  39.     Dstch.  Ztschrft.  f.  Chir.,  vol.  93,  p.  459. 
Fichera :    Anchora  sul  mecanismo  d'azione  dell  iperemia  da 

stasi  nelle-infezioni.     Policlinico,  1908,  Nos.  1,  2. 


LITERATURE.  257 

Fischer,    H.  :   Ein    Doppelscheidenspiegel    gliechgeitig    zum 

(Uiugen  u.  Spuelen.     Miinch.  med.  Woch.,  No.  28,  1908. 
Frangenheim  :    Exper.  Enters,  ill),  d.  Einfluss  d.  Saugbeh. 

auf    lokale    Entziindungsherde.       Arch.     f.     klin.     Chir., 

Ixxxv,  3,  1908. 
Frangenheim  :    Die  Wirkung  d.  Stauungshyp.  im  Tierexperi- 

ment.     Arch.  f.  klin.  Chir.,  vol.  87,  1908,  Xo.  2. 
Frangenheim  :  Miinch.  med.  Woch.,  1908,  Xo.  24. 
Frank,  E.  R.  W.  :    Anwendung  d.  Bierschen  Stauimg  in  d. 

Urologie.     Med.  Klin.,  1908,  p.  787. 
Galli :     Kiinstl.    Hyperaemie    d.   Gehirns    bei    beginnender 

Gehirnarteriosklerose.     ]\Iiinch.  med.  Woch.,  1908,  X'o.  31. 
de  Gaulejac  :    La  methode  de  Bier  en  campagne.    Journ.de 

physiotherap.,  1908,  vi,  117. 
Gebele  :    L^eb.  d.  Beh.  mittels  Hyp.  nach  Bier.     Miinch.  med. 

Wchnschrft.,  1908,  Xo.  3. 
Gelinski :    Die  Heissluftbehandlung  nach  Bauchoperationen. 

Cntrlbltt.  f.  Chir.,  1908,  Xos.  1  und  2. 
V.  Graff :    Experim.  Beitrag.  zur  Erklarung  d.  Wirkungsweise 

d.  Bierschen  Stauimg.     Miinch.  med.  Wchnschrft.,  1908, 

No.  6. 
V.  Graff :   Klin.  u.  experim.  Beitrage  zur  Bierschen  Stauung. 

Beitr.  z.  klin.  Chir.,  Ux,  3,  1908. 
Gregory :    Ueb.   d.   Behandl.   granulierender  durch  Trauma 

erzeugter  Wunden   mit    Bierscher   Stauungshyperaemie. 

Wratschebuaya  Gazeta,  1908,  X"^o.  1. 
Haase :    Passive   Hyperemia    in    Seasickness.     Journ.    Am. 

Med.  Assoc,  1908,  i,  1208. 
Heinrichsen :  Ueb.  d.  Beh.  d.  acut.  und  subacut.  Eiterungen 

mit  Stauungshyp.  nach  Bier.     Arch.  f.    klin.  Chir.,   87, 

1908,  No.  1. 

Hollister  :  The  Relationship  between  Stauungshyperaemia  and 

Opsonic  Index.  Therap.  Gaz.,  Detroit,  1908,  xxxii,  p.  167. 
17 


258  bier's  hyperemic  treatment. 

Iselin :   Behancll.  acut.  eitriger  Entziindung  mit  heisser  Luft. 

Cntrlbltt,  f.  Chir.,  1908,  No.  43. 
Jaschke  :  Stauungshyp.  als  ein  die  Milchsecretion  forderndes 

Mittel.     Med.  Klin.,  1908,  iv,  p.  257. 
Joseph  und  Schliep :   Der  Gewebsstrom  unter  d.  Stauimgs- 

hyperamie.     Dtsch.  med.  Woch.,  1908,  Nos.  11,  12. 
Klapp :    Behandl.  d.  Sehnenscheidenphlegmone.     Berl.  klin. 

Woch.,  1908,  Xo.  15. 
Knopf,F.  A.,andHuey:  Some  Notes  on  the  Etiology,  Prophyl- 
axis    and    Therapeutics     of     Laryngeal     Tuberculosis. 

N.  Y.  Medical  Record,  1908,  February  22. 
Kuhn,  E. :    Physikalische   Behandlung    d.    Lungentuberku- 

lose  durch  Hyperaemie,  Lymphstrombefoocherung  u.  s. 

\v.  vermittels  der  Lungensangmaske.     Zeitsch.  f.  Tuberk., 

1908,  vol.  xiii,  4. 
Lewandowski :    Hyperamie  i.  d.  Therap.  innerer  Krankhtn. 

Berl.  klin.  Woch.,  1908,  No.  10. 
Libessart :    Contribution  a  I'etude  de  la  therap.   par  I'air 

surchauffie.     Arch.  d.  med.  et  de  pharm.  milit.,  Octob., 

1907. 
Lessen :    Ueb.  Biersche  Stauung  u.  Saugbeh.  LXXX.  Vers. 

d.  dtsch.  Naturf.  u.  Arzte,  1908,  20,  ix. 
Lotheissen  :  ZurStauungsbeh.  d.  Eiterungen.    Osterreichische 

Arztezeitung,  1908,  No.  1. 
Lubbert ;   Eine  neue  Methode  d.  Behandl.  mit  Hyperaemie. 

Therap.  Monatsh.,  1907,  No.  11. 
Meyer    and     Schmieden :      Bier's    Hyperemic     Treatment. 

Saunders  Co.,  1908. 
Miles  :   Bier's  Treatment  of  Acute  and  Chronic  Localized  In- 

flamm.  by  Pass.  Cong.     Med.  Times,  1908,  xxxi,  74. 
Muck :    Ein  geheilter  mit  Stauungshyperamie  behand.  Fall 

von  Mittelohrentziindung.     Ztschrft.  f.  Ohrenheilk.,  liii, 

p.  132,  1908. 


LITERATURE.  259 

Muskat :     Stauungshvp.    b.    fixiert.    Plattfuss.     Berl.    klin. 

Wchnschrft.,  1908,  No.  26. 
Ogata,    Kiirhi :     D.    Saugbehandlung   als    scliinerzstilleudes 

Mittel.     Cntrll)ltt.  f.  Chir.,  190S,  Nos.  10-12. 
Pauchet :  La  niethode  de  Bier.     Med.  prat.,  1908,  iv,  p.  165. 
Plass :    Ueb.   d.   Behandl.   mit   Bier's  Stauung.     I^erl.    klin. 

Wchnschrft.,  1908,  xlv,  16. 
Ritter  :  Die  Anwendung  d.  Stauung  h.  Verln-ennung.     Dtsch. 

med.  Wchnschrift.,  1908,  No.  6. 
Ritter,  Carl:  Ein   einf aches   ]\Iittel   gegen   Erbeerchen   beim 

Aetherrausch.     Centralbl.  f.  Chir.,  1908,  No.  28,  p.  843. 
Rocher :    La  thermotherap.   locahsee  dans  les  douleurs  de 

croissance  rebelles.     Journ.  d.  med.  de  Bordeaux,  1908, 

xxxviii,  246. 
Rocher :   Ann  de.  med.  et  chir.  inf.,  1908,  p.  305. 
Schmieden :     Anleitung   z.   Hyperamiebehandkmg.     Reichs- 

mecUcinalkalender,  1908. 
Schmieden  :   Treatment  by  Passive  Hypersemia  with  an  In- 
troduction by  T.  Walker  Hall,  M.D.     Med.  Ann.,  1908, 

Bristol. 
Schmidt :      Bier's    Congestive    Hyperoemia     in     \'eterinary 

Practice.     Am.  \et.  Rev.,  New  York,  1908,  xxxiii,  272. 
Schmidt,  Kurt :    Ueb.  Technik  u.  Wirkung  d.  Stauungshyp. 

u.  Verwertung  i.  Praxis.     Wien.  klin.  Rundschau,  1908, 

Nos.  36,  37. 
Schneider  :    Ueb.  d.  bactericide  und  haemolytische  Wirksam- 

keit  der  Leukocyten  sowie  der  Oedemlymphe.     Miinch. 

med.  Woch.,  1908,  No.  10. 
Schultze,  K.  :  De  la  methode  de  Bier.     Progres  medical,  1908, 

No.  4. 
Schuster  :  Saugbehandl.  im  Mittelalter.     Miinch.  med.  Wchn- 
schrft., 1908,  No.  8. 


260  bier's  hyperemic  treatment. 

Seeligmann :    Anwendg.   d.  Bierschen  Stauung  in  d.  Gyna- 

kolog.     Dtsch.  med.  Wchnschrft.,  1908,  No.  46. 
Carbonell   y    Soles :    El    tratiamento   hiperemico   de   Bier. 

Arch.  d.  ginecol.  Barcelona,  1908,  p.  45. 
Sondermann :    Technik  ii.   Xutzen  d.   Saugbehandlung  bei 

Xasenerkrkng.     Berl.  Klinik,  xx,  1908,  p.  238. 
Stimmel :    Biersche  Stauung  bei  Otitis  med.     Miinch.  med. 

Woch.,  1908,  No.  21. 
Stursberg :   Krit.  und  experiment.  Beitrag.  z.  Frage  d.  Ver- 

wendbarkt.  d.  Bierschen  Stauung  b.  Hirnhautentziindung. 

^liinch.  med.  Wchnschrft.,  1908,  No.  20. 
Svanda :  Biersche  Stauungs-  und  Saugbeh.  i.  d.  Venereologie. 

Wien.  med.  Woch.,  1908,  Nos.  37,  38. 
Szalai :  Die  Hyperamie  i.  d.  Praxis.     Pest.  med.  chir.  Presse, 

1908,  pp.  149,  173,  210. 
Tafel :  Die  Biersche  Stauung  u.  ihre  Beziehung  zur  Chir.  und 

Balneol.     Klin,  therap.  Woch.,  1908,  xv,  1. 
Tarantini :  Sul  mecanismo  diizione  dell  iperemia  da  stasi  alia 

Bier.     Policlinico,  1907,  No.  10. 
Tennant:  The  Application  of  the  Bier  Cup  in  the  Treatment  of 

Recent  Empyema.     Journ.  Am.  Med.  Assoc,  1908,  No.  7. 
Trout,  N.  N.:  Bier's  Hyperemia  in  Surgery.     Virginia  Med. 

Semi-Monthly,  1908,  Aug.  7,  p.  196. 
Winnett :  Bier's  Hypersemic  Treatment  with  Demonstration 

of  Technique.     Canad.  Journ.  Med.  and  Surg.,  1908,  xxiii, 

330. 
Woodward  :  Notes  on  the  Treatment  of  Acute  Inflammations 

by   Bier's  Method   of   Passive    Congestion.      Birmingh. 

Med.  Rev.,  1908,  Ixiii,  79. 
Wrede :   A  Criticism  of  the  Treatment  of  Acute  Suppurative 

Infections  by  Passive  Hypersemia  and  Cupping  as  Advo- 
cated   by    Professor    Bier.     Surgery,    Gynecology,    and 

Obstetrics,  September,  1908,  288-293. 


LITERATURE.  261 

Zangetneister :     Die    Behanclluiig    d.    puerperalen    Mastitis 

mit  .Saugapparat.     Dtsch.  med.  Wchnschrft.,  1908,  No.  6. 
Zickgraf :      Behandlung    der    Lungentuberculose    mit    der 

Kuhnschen  Saugmaske.     Cntrlbltt.   f.   inn.   Med.,    1908, 

No.  39. 
Tracy :     Active    Hypersemia    by    Hot    Air.     Med.    Council, 

Phila.,  1908,  xiii,  62. 
Tracy  :    Hyperaemia  as   a  Therap.  Agent.     Am.   Clin.  Med., 

1908,  XV,  70. 
Tufl&er :    L'hyperemie  veineuse  dans  les  infections  aigues  des 

membres.     Bull,  et  memoires  d.  la  soc.  de  chir.  de  Paris, 

1908,  xxxiii,  p.  169. 
Turner :      Hypersemia    as    a    Therap.    Agent.      Am.    Journ. 

Orthop.  Surg.,  1908,  v,  425. 
Ullmann:     Saughyperaemie    an     d.    Prostata.    Ztschrft.    f. 

Urol,  Bd.  2,  No.  9,  1908. 
Vasek:    Die  Therap.  einiger  chirurg.    Erkrankungen  mittels 

passiver  Hyperaemie  nach  Bier.     Casopis  lekaru  veskych, 

1908,  p.  885. 
Vogel :  Ueber  Gelenktuberkulose.    Deutsch.  Zeitschr.  f.  Chir- 

urgie,  1908,  Bd.  97. 
Waterhouse  :    An  Address  on  Bier's  Treatment  by  Means  of 

Induced  Hypersemia.     Brit.  Med.  Journ.,  July  18,  1908. 
Westmann  :  Bier's  Hypersemia  as  a  Therap.  Agent.     Canad. 

Pract.  and  Rev.,  xxxiii,  1908,  211. 
Wilson :     An   Account   on   the   Method   of   Controlling   the 

Pressure  of  the  Bandage  in  Bier's  Hypersemic  Treatment. 

Journ.  of  Am.  Med.  Assoc,  1908,  1,  p.  1422. 


INDEX  TO  BIBLIOGRAPHY 


Abrand,  2-16 
Adams,  235 
Albeker,  246 
Alexander,  235 
Ambrosini,  225 
Amitin,  Sarah,  218 
Arnsperger,  229 
Auffert,  235,  247 
Axamit,  247 


Babler,  235 
Bachmann,  221,  223 
Baetzner,  255 
Balli,  Ettore,  220 
Ballin,  247 
Bango,  247 
Barcroft,  247 
Bardenheuer,  235 
Bart,  247 
Bauer,  229,  235 
Baum,  229 
Bauman,  235 
Baumbach,  235 
Biiumler,  221 
Beaty,  255 
Beckman,  229,  247 
Beer,  235 
Bendig,  247 
Berard,  235 
Bering,  229 
Berlin,  229 
Berner,  229 
Bemheim,  255 
Berry,  247 
Besson,  247 
Bestelmeyer,  235 
Bie,  229 


Biehler,  235 

Bier,  217,  218,  219,  220,  221,  222, 

223, 224, 225, 226, 227, 229, 230, 

231,  235,  247 
Binnie,  255 
Blanc,  236 
Blecher,  224,  255 
Bohme,  236 
Bonheim,  236,  247 
Borbely,  247 
Boshouwers,  236 
Bouman,  247 
Braatz,  256 
Bradford,  236 
Braun, 230 
Breiger,  236 
Breuer,  230 
Brewer,  236 
Brooks,  256 
Brown,  256 
Brunn,  236 
Brunn,  Max,  230 
Buchner,  218,  222 
Bum,  230 
Burckhart,  247 
Burk,  236 
Burn-Murdoch,  248 
Burwinkel,  225,  230 
Buschke,  218 


Canel,  248 
Canon,  236 
Carbonell  y  Soles,  260 
Carl,  W.,  256 
Cathcart,  236 
Chlumsky,  221 
Chvostek,  218 


263 


264 


IXDEX    TO    BIBLIOGRAPHY 


Clement,  230,  23') 
Codman,  236 
Colle,  237 
Colley,  237 
Comolli,  256 
Corner,  248 
Cossart,  237 
Coste,  256 
Czylharz,  223 


Danielsex,  230,  256 
Dauwe.  237,  256 
Debeyre,  237 
Decref,  248 
De  Gaulejac,  238,  257 
Dehio,  227 
Delageniere,  237,  248 
Delfino,  237 
Berlin,  230 
Dessauer,  256 
Deutschliinder,  237,  248 
Dick,  256 
Donarth,  223 
Donati,  237 
Duclaux,  248 
Ducrotoy,  250 
Durey,  256 


Ebermeyer,  239 
Eiselsberg,  230 
Elting,  237 
Enderlen,  237 
Englander,  237 
Esch,  237,  248 
Eschweiler,  248 
Eversmann,  230,  237 
Ewald,  222 


Fasiani,  256 
Faure,  238 
Fein,  238 
Felegyhazi,  256 
Feleki,  238.  248 
Ferrari,  238 


Fichera,  238,  248,  256 
Fischer.  C,  230 
Fischer,  H.,  257 
Fischer,  M.,  238 
Fleischmann,  238 
Flett,  248 
Folet,  237 
Forchhammer,  224 
Fraenkel.  248 
Franck,  Francois,  217 
Frangenheim,  257 
Frank,  E.  R.  W.,  257 
Frankel,  230,  238 
Frankl,  230,  238 
Frey,  223 

Frommer,  230,  238 
Frose,  248 
Fiirst,  238 
Futaki,  249 


Galli,  257 
Gangele,  238 
Gebele,  239,  257 
Gelinski,  257 
Gerson,  248 
Girard,  230 
Gobel,  239 
Goldscheider,  219 
Goltz,  222 
Gorse,  239 
Goyanes,  239 
Gramenitzki,  239,  248 
Grammenitzki,  248 
Grawitz,  239 
Gregory,  257 
Gnibe,  239 
Gruber,  249 
Griinbaum,  230 
Guth,  239 
Guyot,  239 


Haase,  257 

Habs,  226,  231,  239 

Hahn,  220 

Hamburger,  220,  221,  222 


INDEX    TO    BIBLIOGRAPHY 


205 


Hanusa.  226 
Hartmann,  249 
Hasslauer.  239 
Hauffe.  239 
Hausler.  239 
Haymann,  239 
Heermann,  239 
Heidenhain.   240 
Heile.  231 
Heine,  231 
Heinrichsen.  2o7 
Heinsius,  249 
Heinz.  224 
Helferich,  217 
Heller,  240 
Henle,  221,  227 
Henriksen,  249 
Herhold,  240 
Herz,  220,  226 
Hesse,  240 
Heyde.  240 
Hildebrandt,  221 
Hilgenreiner,  249 
Hirsch,  231 
Hochhaus,  231 
Hoffheinz,  226 
Hofmann.  231 
Hofmeister,  225 
Hollister.  257 
Homberger,  240 
Honigmann,  249 
Honneth,  231 
Hoppe,  240,  249 
Huey,  258 
Huth,  221 


ISELIN,  258 

Isemer,  240,  243 


Jacob,  219 
Jacoby,  220 
Jacoby,  S.,  240 
Jansen,  231 
Jaschke,  258 
Jaworski,  249 


Jerusalem.  231.  240.  249 
Jordine.  240 
Jo.seph.  231.  240.  258 
Joseph.  Eugen.  240 
Joynt,  231 


Kaefer,  240 

Kauffmann.  224 

Keppler,  231,  232 

Key, 232 

Kirchhoff,  241 

Klapp,  223,    225.    226.    230,    232. 

241,  249,  258 
Kleine.  224 
Klemperer,  249 
Knopf,  F.  A.,  258 
Koch,  Carl,  241 
Koda,  249 
Kohlhardt,  224 
Konig,  241 
Kopetzky,  241 
Koster,  227 
Kothe,  227 
Kozlowski,  241 
Krause,  222 
Kromer,  249 
Kuhn,  241,  250 
Kuhn,  E.,  241,  258 
Kuhne,  249 
Kushtaloff,  250 


Laccetti,  241 
Lamberger,  232 
Lammerhirt,  241 
Lang,  241 

Langemak,  222,  228 
Langmann,  223 
Laqueur,  228,  232 
Laspeyres,  225 
Lazarus,  242 
Ledent,  250 
Le  Fort,  241 
Lemire,  250 
Leo,  241 
Lermoyez,  225 


266 


INDEX   TO   BIBLIOGRAPHY 


Leser,  232 
Leutert.  250 
Leuwer,  242,  250 
Lewandowski ,  258 
Lewith,  250 
Lexer,  242 
Leyden,  242 
Libessort,  258 
Lichtenstein.  250 
Lick,  226 
Lindemann,  221 
Lindenstein,  242 
Link.  226 
Lissauer,  249 
Lommel.  227.  232 
Lossen,  232,  235,  242,  258 
Lotheissen,  258 
Lowenhardt,  221,  222 
Lowy,  219 
Liibbert,  250.258 
Lumniczer,  250 
Luthi,  232 
Luxembourg.  227,  228 


Mahx.  225 

Maire.  250 

Makara.  250 

Manninger,  232,  242 

Maragliano,  242 

Marehand,  223 

Marcuse.  232.  233 

Martin.  227.  233,  242 

Masskow,  221 

Masuati,  219 

Matthes.  227,  228,  242 

Mautner,  242 

Mayer,  L.,  242 

Mcllhenny,  242 

Mcintosh,  250 

McLennan,  250 

Meltzer,  223 

Mendelsohn.  221 

Metchnikoff,  218 

Meyer,  W.,  219,  224,  227,  251,  258 

Miles,  258 

Miller.  219 


Mindes,  242 
Minkowski.  233 
Mislowitzer,  243 
Moll.  243 

Momburg.  228,  233 
Moore,  243 
Moritz.  228,  251 
Moschcowitz,  Eli,  243 
Mosetig,  233 
Muck.  251.  258 
Miiller.  243 
Murdoch.  251 
Muskat,  259 


Necker.  233 
Negri,  219 
Nenadovics,  251 
Neu,  243,  251 
Neumann.  228 
Nicoladoni,  217 
Nicolai,  219 
Nobili,  251 
Nordmann,  243 
Notzel,  220,  222,  223 
Nyrop,  243 


Ogata,  Kiirhi,  259 
Onodi,  243 
Oppenheim,  251 


Pal,  251 
Palmer,  243 
Par^.  Ambroise,  217 
Pauchet.  259 
Paul,  251 
Payr,  233 
Penzo,  220,  233 
Perl,  251 
Perthes,  224,  243 
Petersen,  219,  251 
Pezold,  243 
Pfaun, 243 
Pick,  227 
Pietrowski,  218 


INDEX    TO    BIBLIOGKAPHY 


267 


Plaskuda,  227,  228 
Plass,  259 
Pogne,  243 
Polini,  243 
Politzer,  243 
Pollak,  251 
Polydk,  244 
Pospieloff,  252 
Pribram,  226 
Prym,  233 
Putzler,  252 


Ranzi,  233,  244 

Rattner,  244 

Raudnitz.  244 

Rautenberg,  226,  233 

Reclus,  252 

Redlich,  218 

Reineboth,  223,  224 

Reitler,  223 

Renner,  244 

Ret  hi,  244 

Ribbert,  233 

Richter,  218,  219 

Riedl,  252 

Risquez,  244 

Ritter,  225,  226,  233,  244,  252,  259 

Ritter,  Carl,  259 

Robbers,  244 

Roberts,  252 

Robins,  252 

Rocher,  259 

Rolleston,  228 

Ropke,  252 

Rosenberger,  252 

Roth,  226 

Rotter,  252 

Rube,  233 

Rubritius,  244 

Rudolph,  233 


Sabzer,  234 
Salkindsohn,  252 
Sargeant,  220 


I   Sauer,  252 

Savelle,  244 

Schade,  252 

Schaffer,  226 
!   Schaffer,  249,  253 

Schattmann,  253 

Scheibe,  244 

Scheme!,  228 

Schenk,  225 

Scheuer,  244 

Schlaeger,  253 

Schlatter,  253 

Schliep,  258 

Schmidt,  253,  259 

Schmidt,  Kurt,  259 

Schmieden,  244,  253,  258,  259 

Schneider,  259 

Schonberg,  244 

Schongut,  245 

Schultze,  K.,  253,  259 

Schuster,  259 

Schrakamp,  218,  227,  228 

Schreiber,  225 

Schwarz,  F.,  219 

Schwarze,  245 

Seelig,  253 

Seeligmann,  260 

Sibley,  Knoxley,  220 

Sick,  234,  253 

Sommer,  227 

Sondermann,  234,  245,  260 

Spiess,  234 

Sprouck,  221 

Stahr,  245 

Stein,  253 

Steinitz,  254 

Stenger,  245 

Stern,  254 

Stiassny,  254 

Stich,  234,  245 

Stimmel,  260 

Stolzenburg,  254 

Strauss,  245 

Stursberg,  260 

Sudeck,  226 

Svanda,  260 

Szalai,  254,  260 


268 


INDEX    TO    BIBLIOGRAPHY 


Tafel.  260 
Tarantini.  254.  260 
Tautzscher,  254 
Taylor,  222 
Tennont,  260 
Thiem,  224 
Thierry,  245 
Thole.  245 
Thomas,  217 
Thorbeke,  245 
Tillmanns.  234 
Tomaschewski,  245 
Tomita,  Chutaro.  254 
Tracy.  260 
Tranc-Rainer,  245 
Trout.  260 
Tuffier.  254,  260 
Turan.  245 
Turner.  260 
Tuszai,  228 


Ullmann,  225,  234,  245,  260 


Van  Lier,  242 
Van  Swieten,  234 
Vander  Veer,  246,  254 
Vasek,  261 
Venus.  246 
Viannay,  246,  254 
Villemin.  254 
Vogel,  254,  261 
Vohsen,  254 
Volk,  234 

Von  Baumgarten,  235 
Von  Esmarch,  218 
Von  Graff,  257 
Von  K65sa,  219 
Von  Mikulicz,  218,  228 


Von  Schlaffer,  223 
Von  Statzer,  227 
Von  Tiling,  234 
Vorschutz,  255 


Wagner.  219 
Walsh.  224 
Walter.  246.  255 
Wassermann.  234 
Waterhouse.  261 
Wechsberg,  222,  234 
Weecke,  246 
Weil.  222,  255 
Weinbrenner,  255 
Weinlechner,  234 
Wessel,  234.  246 
Wessely,  246,  255 
Westmann,  261 
Wiedmann,  228 
Wiener,  228,  246 
Wilson,  222,  261 
Winnett,  261 
Winternitz,  221,  235 
Witzel.  235 
Wolf.  255 
Wolflf-Eisner,  246 
Woltersdorf,  220 
Woodward,  261 
Wrede,  255,  261 
Wulf,  255 
Wyman,  246 


Zabel,  255 
Zacharias.  255 
Zangemeister,  261 
Zeller,  219 
Zickgraf,  261 
Zimmermann.  246 


GENERAL  INDEX 


Abscess,  cold,  in  tuberculosis  of 
joints,  treatment,  142 
of  testicle,  treatment,  lo4 
wandering,  loS 
due  to  tuberculous  glands,  152 
obstructive  hyperemia  by  elas- 
tic bandage  in,  34 
by  suction  in,  51 
of  axilla,  suction  hyperemia  in, 

91 
over  mastoid  process,  194 

technique,  195 
periarticular,  105 
suction  hyperemia  in,  90 
with  acute  parotitis,  96 
Absorption,  favoring,  22 
Accessory  sinuses  of  nose,  chronic 

diseases  of,  203 
Acne,  210 

Adenitis,  inguinal,  191 
Adhesions,  intraperitoneal,  170 
Advantages  over  other  methods, 

21 
Air,  hot,  25 

obstructive  hyperemia  by,  64 
burns  from,  71 
passages,  upper,  dry  catarrh  of, 
203 
Alopecia  areata,  211 
Ambulatory    treatment  in  tuber- 
culosis of  joints,  150 
Anal  fistula,  incomplete,  159 
Anesthesia,  ether,  vomiting  after, 
hyperemia  to  prevent,  128 
spinal,    hyperemia   to    prevent 
after-elYects,  128 
Angina,  acute,  203 
chronic,  205 


Antrum  of  Highmore,  disease  of, 
202 

Arm,  subcutaneous  phlegmon  of, 
118 

Arteriosclerosis,  care  in,  39 

Artery,  main,  embolism  of,  gan- 
grene due  to,  168 

Arthritis  deformans,  162 
chronic,  161 
gonorrheal,  101 
urica,  163 

Arthrotomy  with  drainage  last 
resort  in  acute  infectious  in- 
flammation of  joints,  104 

Articular  rheumatism,  acute,  172 
chronic,    161 

Artificial  increase  of  inflammation, 
19 

Atrophy,  progressive  optic,  199 

Avoidance  of  suppuration,  21 

Axilla,  abscess  of,  suction  hy- 
peremia in,  91 


Bandage,  elastic,  23 

obstructive  hyperemia  by,  26 
dressings  during,  32 
duration  of   application, 

35 
edema  in,  33 
feeling  pulse  in,  26 
in  abscess,  34 
intermission  periods,  33 
looseness  in,  27 
means  of  increasing,  33 
no  increase  of  pain  in,  27 
of  head,  38 
of  shoulder-joint,  37 


269 


270 


INDEX 


Bandage,  elastic,  obstructive  hy- 
peremia by,  of  testicles, 

41 
prevention  of  decubitus 

in,  37 
proper  measure  of  com- 
pression in,  27 
tightness  in,  27 
warmth  in,  31 
who  is  to  apply,  35 
Bartholinitis,  191 
Bibliography,  217 
Blood  current,  17 
Bone,  temporal,  acute  inflamma- 
tory process  of,  195 
Bone-metastasis      following      ty- 
phoid, 177 
Box,  hot-air,  for  chronic  rheuma- 
tism of  shoulder,  162 
for  elbow,  67 
for  foot,  70 
for  hand,  66 
for  hips,  73 
for  knee,  71 
for  leg,  72 
for  shoulder,  68 
Boxes,  hot-air,  67 

universal,  76 
Brisement  force,  163 
Burn,  18 

first  stage,  18 
from  hot-air,  71 
hyperemia  for,  170 
second  stage,  18 
third  stage,  18 


Carbuncles,  84 

suction  treatment  of,  84 
dressings  in,  85 
duration,  85 
incision  in,  85 
size  of  cups  in,  86 
technique  of  treatment  for,  84 
Carcinoma,  171 

Catarrh,  dry,   of  upper  air   pas- 
sages, 203 


Cavernitis,  191 

Cerebrospinal  meningitis,  173 
epidemic,  173 
lumbar  puncture  with  hyper- 

emic  treatment  in,  173 
suppurative,  173 
tuberculous,  173 
Cervix  uteri,  suction  glasses  for, 

185 
Chancre,  hard,  191 
Cholesteatoma  of  middle  ear,  196 
Chorea,  207 

Huntingdon's,  207 
minor,  207 
Cicatrices,  ugly,  prevention,  124 
Club-foot,  164 

Cold    abscess    in    tuberculosis    of 
joints,  treatment  of,  142 
of  testicle,  treatment  of,  154 
wandering,  153 
in  head,  202 
Colles's  fracture,  81 
Compound  fractures,  obstructive 
hyperemia  for,  128 
of  base  of  skull,  obstructive 
hyperemia  for,  129 
Compression,  proper  measure  of, 
in    obstructive    hyperemia    by 
elastic  bandage,  27 
Conjunctiva,    inflammatory    dis- 
eases of,  200 
Contractures    in    tuberculosis    of 

joints,  138 
Contusions,  79 
of  fingers,  79 
Corpuscles,  rice-,  158 
Coryza,  acute,  202 
Cupping  glasses,  24 


Dacryocystitis,  acute,  199 
Decubitus,     prevention,     in     ob- 
structive hyperemia  by  elastic 
bandage,  37 
Delayed  union  of  fracture,  82 
Deposits,   periurethral   inflamma- 
tory, 191 


INDEX 


271 


Dermatology,     hyperemic     treat- 
ment in,  210 
Diabetic  gangrene,  16S 
Diabetics,  furuncles  in,  S7 
Diphtheria,  173 
Diseases,  treatment,  78 
Disinfection  in  obstructive  hyper- 
emia by  suction,  49 
Distortions,  79 
Douche,  hot-air,  76 
for  neuralgia,  74 
for  sciatica,  75 
Dressings       during       obstructive 
hyperemia   by   elastic   band- 
age, 32 
in    suction    treatment    of    fur- 
uncles and  carbuncles,  85 
in  treatment  of  felon,  106, 113 
when  suction  cups  are  used,  53 
Dry  catarrh  of  upper  air  passages, 

203 
Duration    of    application    of    ob- 
structive     hyperemia, 
35 
by  suction,  52 
Dysmenorrhea,  186 


Ear,  diseases  of,  194 

middle,  cholesteatoma  of,  196 
chronic  inflammation  of,  ex- 
acerbation of,  194 
Eczema,  acute,  210 

chronic,  210 
Edema  in  obstructive  hyperemia, 

33 
Elastic  bandage,  23 

obstructive  hyperemia  by,  26 
dressings  during,  32 
duration   of  application, 

35 
edema  in,  33 
feeling  pulse  in,  26 
in  abscess,  34 
intermission  periods,  33 
looseness  in,  27 
means  of  increasing,  33 


Elastic  bandage,  obstructive  hy- 
peremia by.  no  increase 
of  pain  in,  27 
of  head.  38 
of  shoulder-joint,  37 
of  testicles,  41 
prevention   of  decubitus 

in,  37 
proper  measure  of  com- 
pression in.  27 
tightness  in,  27 
warmth  in,  31 
who  is  to  apply,  35 
neck-band,  39,  40 
Elbow-joint,  hot-air  box  for,  67 

suction  apparatus  for,  62 
Embolism   of   main   artery,   gan- 
grene due  to,  168 
Empyema,  91 

Epidemic  cerebrospinal  meningitis, 
173 
poliomyelitis,  209 
Epididymitis,    acute    gonorrheal, 
189 
subacute  gonorrheal,  190 
Epilepsy,  208 
Erysipelas,  118,  121 
Etherization,  vomiting  after,  hy- 
peremia for,  128 
Eye,  diseases  of,  199 

technique  of  treatment  in,  199 
Eyelids,     inflammatory     diseases 
of,  200 


Face,    acute     infectious     inflam- 
mations of,  94 
furuncles    of,    obstructive    hy- 
peremia in,  90 

Facia  necrosis,  94 

False  joint,  82 

Felon,  105 

after-treatment,  113 
dressing  in  treatment  of,  106, 113 
incision  in  treatment  of,  106 
Klapp's  incisions  for.  111,  112 
technique  in  treatment  of,  106 


272 


INDEX 


Fifth  nerve,  neuralgia  of,  206 
Fingers,  contusions  of,  79 

injuries  of,  during  operations, 
obstructive      hyperemia 
for,  126 
obstructive  hyperemia  for,  125 
Fistula  in  ano,  incomplete,  159 

tooth,  95 
Flat  foot,  inflammatory,  164 
Floor    of    mouth,    phlegmon    of, 

95 
Foot,  club,  164 

flat,  inflammatory,  164 
hot-air  box  for,  70 
Forearm,  infected,  Klapp's  method 

of  incising,  111,  112 
Fracture,  Colles's,  81 

compound,  obstructive  hypere- 
mia in,  128 
of  base  of  skull,  obstructive 
hyperemia  in,  129 
delayed  union  of,  82 
joint,  81 
Frontal  sinusitis,  acute,  202 
Frost  bites,  170 
Furuncles,  84 
in  diabetics,  87 
of  face  and  neck,   obstructive 

hyperemia  in,  90 
of  lip,  suction  hyperemia  in,  88 

technique,  88 
suction  treatment  of,  84 
dressings  in,  85 
duration,  85 
incision  in,  85 
size  of  cups  in,  86 
technique  of  treatment  for,  84 
Furunculosis,  lymphangitis  with, 
87 
multiple,  86 
suction  hyperemia  in,  86 


Gangrene,  diabetic,  168 

due  to  embolism  of  main  artery, 

168 
senile,  168 


Genito-urinary    surgery,    hypere- 

mic  treatment  in,  188 
Glands,  tuberculous,  abscesses  due 

to,  152 
Glass,  suction,  for  puerperal  mas- 
titis, 48,  49 
Glasses,  cupping,  24 

suction,  46,  47,  50,  51 
Gonorrhea,  acute,  188 

ascending,  in  female,  190 
Gonorrheal  arthritis,  101 
epididymitis,  acute,  189 

subacute,  190 
joint  inflammations,  acute,  191 

chronic,  191 
prostatitis,  acute,  189 

subacute,  190 
urethritis,  subacute,  190 
vesiculitis,  subacute,  190 
Gout,  163 

Granulating  wounds,  93 
Gynecology,      hyperemic      treat- 
ment in,  184 
suction  hyperemia  in,  184 
indications,  185 
technique,  184 


Hand,  hot-air  box  for,  66 

infected,  Klapp's  method  of  in- 
cising, 111,  112 
injuries  of,  obstructive  hypere- 
mia for,  125 
Hard  chancre,  191 
Hay  fever,  203 
Head,  cold  in,  202 

obstructive  hyperemia   by  elas- 
tic bandage  of,  38 

awakening  from  stupor 
after,  131 
Headache,  207 
Highmore,  antrum  of,  diseases  of, 

202 
Hips,  hot-air  box  for,  73 
Hot-air,  25 

box  for  chronic   rheumatism  of 
shoulder,  162 


INDEX 


273 


Hot-air  box  for  elbow,  C)7 
for  foot,  70 
for  hand,  66 
for  hips,  73 
for  knee,  71 
for  leg,  72 
for  shoulder,  68 
open,  65 
boxes,  67 
douche  for  sciatica,  75 

for  trigeminal  neuralgia,  74 
douches,  76 
hyperemia,  24 

in  arthritis  deformans,  162 
in  chronic  arthritis,  161 
in  frost  bites,  170 
in  gangrene,  168 
in  inflammatory  flat  foot,  164 
in  neuralgia,  206 
in  sciatica,  206 
in  scoliosis,  166 
in  ulcers  of  leg,  168 
obstructive  hyperemia  by,  64 
burns  from,  71 
Huntingdon's  chorea,  207 
Hydrops,  traumatic,  of  knee,  80 

tuberculous,  of  knee,  80 
Hygroma,  tuberculous,  158 
Hyperemesis  gravidanun,  hypere- 
mia for,  128 
Hypertrophic  tonsils,  205 


Ice-bag,  mistake  to  use,  20 
Ilio-sacral  joint,   tuberculosis  of, 

146 
Inducing  hyperemia,  methods  of, 

23 
Infected      hand      and      forearm, 
Klapp's  method  of  incising, 
111,  112 
wounds,  obstructive  hyperemia 
in, 122 
suction  hyperemia  in,  93 
Infections,  acute,  84 
chronic,  131 
suppression  of,  21 
18 


Infectious  inflammation,  acute, 
of  joints,  101.  See  also 
Joints,  acute  infectious 
inflammation  of. 
within  mouth  and  of  face, 
94 
Infiltrations,  tuberculous,  of  soft 

tissues,  158 
Inflammation,  84 

acute  infectious,  of  joints,  101. 
See     also     Joints,    acute 
infectious     inflammation 
of. 
within  mouth  and  of  face, 
94 
of  temporal  bone,  195 
artificial  increase  of,  19 
chronic,   joint   stiffness   follow- 
ing, 163 
brisement  force  in,  163 
middle-ear,   exacerbation   of, 

194 
not  due  to  specific  bacteria, 
161 
definition,  18,  19 
joint,  acute  gonorrheal,  191 

chronic  gonorrheal,  191 
puerperal,  of  knee,  187 
Inflammatory    deposits,    periure- 
thral, 191 
diseases  of  eyelids,  200 
flat  foot,  164 
Inguinal  adenitis,  191 
Injuries  of  fingers  and  hands,  ob- 
structive hyperemia  for,  125 
during    operations,    obstruc- 
tive hyperemia  for,  126 
Intermission  periods    in    obstruc- 
tive hyperemia,  33 
Intracranial  complications  in  hy- 
peremic   treatment   in  otology, 
196 
Intraperitoneal  adhesions,  170 
Introduction,  17 
lodin,  tincture  of,  to  prevent  ugly 

scars,  124 
Irritability,  mental,  208 


274 


INDEX 


Joints,   acute    infectious    inflam- 
mation of,  101 
arthrotomy   with   drain- 
age last  resort  in  treat- 
ment, 104 
duration    of     treatment, 

105 
evacuation     of     pus     in 

treatment,  103 
fever  in,  105 
indications      for      treat- 
ment, 101 
irrigation     of    joints     in 

treatment,  103 
movements      in      treat- 
ment, 102 
technique  of  treatment, 

102 
time  of  treatment,  102 
fracture  of,  81 

iUo-sacral,  tuberculosis  of,  146 
inflammations  of,  acute  gonor- 
rheal, 191 
chronic  gonorrheal,  191 
injury  of,  79 

perforative  wounds  of,  104 
stifTened,  utility   of  large  suc- 
tion apparatus  for  mobilizing, 
55 
stiffness    of,    following    inflam- 
mation, 163 
brisement  force  in,  163 
tuberculosis  of,  131.     See    also 
Tuberculosis  of  joints. 


Keloids,  211 

Keratitis,  parenchymatous,  200 

Kidney,     tuberculosis     of,     after 

nephrectomy,  193 
Klapp's    method   of    incising    in- 
fected hand  and  forearm,  111, 
112 

suction  cup,  87 
Knee,  hot-air  box  for,  71 

puerperal  inflammation  of,  187 

suction  apparatus  for,  62 


Knee,  traumatic  hydrops  of,  80 
tuberculosis  of,  cured,  141 
tuberculous  hydrops  of,  80 
Knee-stretching,   suction   appara- 
tus for,  63 
Kuhn's  lung  suction  mask,   175, 
176 
in  laryngeal  tuberculosis, 
205 

Labyrinth,  diseases  of,  197 
Lactation,  deficient,  187 
Laryngology,     hyperemic    treat- 
ment in,  202 
Larynx,  diseases  of,  202 

tuberculosis  of,  205 
Leg,  hot-air  box  for,  72 
ulcer  of,  168 

syphilitic,  161,  168 
Lip,  furuncle  of,  suction  hypere- 
mia in,  88 
technique,  88 
Locomotor  ataxia,  209 
Looseness  of  elastic  bandage,  27 
Lumbago,  181 

Lumbar   puncture,    improvement 
after,  209 
in  cerebrospinal      meningitis 
with  hyperemic  treatment, 
173 
Lung  suction  mask,  175,  176 
Lupus,  211 
Lymphadenitis,  91 
Lymphangitis,  118 
of  lower  extremity,  87 
with  furunculosis,  87 

Malignant  disease,  170 
Mask,  lung  suction,  175,  176 
Massage,     suction,     in     posterior 

parametritis,  186 
Mastitis,  puerperal,  187 

suction  glass  for,  48,  49 
hyperemia  in,  96 

evacuation  of  milk,  98 
operative  treatment,  99 


INDEX 


J.t6 


Mastoid  process,  abscess  over,  194 

technique,  195 
Mastoiditis,    acute    otitis    media 

with,  194 
Maxillary  sinusitis,  acute,  202 
Medicine,     hyperemic     treatment 

in,  171,  172 
Melancholia,  208 
Meningitis,  cerebrospinal,  173 
epidemic,  173 

lumbar    puncture    with    hy- 
peremic treatment  in,  173 
suppurative,  173 
tuberculous,  173 
spinal,  208 
Mental  diseases,  hyperemic  treat- 
ment in,  206 
irritability,  208 
Metastatic  parotitis,  96 
Methods   of   inducing  hyperemia, 

23 
Milk,  evacuation  of,  in  puerperal 

mastitis,  98 
Mouth,    acute    infectious    inflam- 
mations within,  94 
floor  of,  phlegmon  of,  95 
Multiple  furunculosis,  86 
Mumps,  96 

metastatic,  90 
Mycotic  diseases  of  nail,  210 


Nail,  diseases  of,  210 
mycotic  diseases  of,  210 

Neck,  furuncles  of,  obstructive 
hyperemia  in,  90 

Neck-band,  elastic,  39,  40 

Necrosis,  fascia,  94 

Nephrectomy,  tuberculosis  of  re- 
maining kidney  after,  193 

Nerve,  fifth,  neuralgia  of,  206 

Nervous  diseases,  hyperemic  treat- 
ment in,  206 
system,  central,  diseases  of,  207 

Nervous  system,  diseases  of,  im- 
provement after  lumbar  punc- 
ture in,  209 


Neuralgia,  206 
of  fifth  nerve,  206 
trigeminal,   hot-air  douche  for, 
74 
Neurology,  hyperemic    treatment 

in,  206 
Nose,  accessory  sinuses  of,  chronic 
diseases,  203 
diseases  of,  202 
chronic,  203 
suction  apparatus  for,  203 


Obstetrics,    hyperemic   treat- 
ment in,  184 
Obstructive  hyperemia,  23,  24 
as  a  prophylactic,  122 
by  elastic  bandage,  26 
dressings  during,  32 
duration  of   application, 

35 
edema  in,  33 
feeling  pulse  in,  26 
in  abscess,  34 
intermission  periods,  33 
looseness  in,  27 
means  of  increasing,  33 
no  increase  of  pain  in,  27 
of  head,  38 

awakening  from  stupor 
after  131 
of  shoulder-joint,  37 
of  testicles,  41 
prevention   of  decubitus 

in,  37 
proper  measure  of  com- 
pression in,  27 
tightness  in,  27 
warmth  in,  31 
who  is  to  apply,  35 
by  hot-air,  64 

burns  from,  71 
by  suction,  44 

apparatus  of  large  size  in,  54 
utility  for  mobilizing 
stiffened    joints, 
55 


276 


INDEX 


Obstructive    hyperemia    by   suc- 
tion, disinfection  in,  49 
dressings  in,  53 
duration  of  application  in, 

52 
effect  of,  44 
in  abscess,  51 
mechanical  effect  of,  47 
technique,  45 
in  bums,  170 
in  chronic  arthritis,  162 
in  compound  fracture,  128 

of  base  of  skull,  129 
in  furuncles  of  face  and  neck, 

90 
in    hyperemesis  gravidarum, 

128 
in  injuries   of   fingers   and 
hands,  125 
during  operations,  126 
in  pyorrhea  alveolaris,  94 
in  rabies,  127 
in  snake  bites,  127 
in  soiled  wounds,  122 
in  tuberculosis  of  joints,  133 
duration  of,  133 
technique,  135 
in  vomiting  of  pregnancy,  128 
to     prevent     after-effects    of 
spinal  anesthesia,  128 
to   prevent   vomiting  after 
etherization,  128 
Operations,   injuries      of      fingers 
during,   obstructive   hyperemia 
for,  126 
Ophthalmia,  sympathetic,  200 
Ophthalmology,   hyperemic  treat- 
ment in,  199 
Optic  atrophy,  progressive,  199 
Os  sacrum,  tuberculosis  of,  146 
Osteomyelitis,  acute,  118 

recurrent,  121 
Osteoperiostitis,  181 
Otitis    media,  acute,   with    mas- 
toiditis, 194 
chronic,  196 
exacerbation  of,  194 


Otology,  hyperemic  treatment 
in,  194 
intracranial   complications, 
196 


Paix,  diminution  of,  22 

no   increase  of,   in   obstructive 
hyperemia   by   elastic   band- 
age, 27 
Panaritium,  105.     See  also  Felon. 
Parametritis,  chronic,  184 
posterior,  186 

suction  massage  in,  186 
Parenchymatous  keratitis,  200 
Paronychia,  105.     See  also  Felon. 
Parotitis,  96 
metastatic,  96 
with  abscess,  96 
Parulis,  95 
Pathologic      process,      hastening 

course  of,  22 
Perforative  wounds  of  joints,  104 
Periarticular  abscess,  105 
Perimetritis,  184 
Peritoneum,  tuberculosis  of,  159 
Periurethral     inflammatory     de- 
posits, 191 
Pes  varus,  164 

Pharyngology,    hyperemic    treat- 
ment in,  202 
Pharynx,  diseases  of,  202 
Phlegmon  of  floor  of  mouth,  95 
of  tendon-sheaths,  107 

advance  of  infectious  process, 

109 
after-treatment,  113 
anatomic  description  of,  109 
dressing,  113 
evacuation  of  pus  in,  112 
exercises  with  fingers  in  treat- 
ment of,  114 
incision  in  treatment  of,  112 
Klapp's     incisions    for.    111, 

112 
technique  of  treatment  of,  108 
subcutaneous,  of  arm,  118 


INDEX 


277 


Poliomyelitis,  209 
acute,  209 
epidemic,  209 
Pott's  disease  of  spine,  145 
Pregnancy,  vomiting  of,   hyp?re- 

mia  for,  128 
Principle  underlying  treatment,  19 
Prophylactic,      obstructive      hy- 
peremia as,  122 
Prostate,   suction    apparatus   for, 
189 
tuberculosis  of,  191 
Prostatitis,  acute   gonorrheal,  189 

subacute  gonorrheal,  190 
Pseudoarthrosis,  82 
Psoriasis,  210 
Psychiatry,  hyperemic  treatment 

in,  206 
Puerperal    inflammation  of  knee, 
187 
mastitis,  187 

suction  glass  for,  48,  49 
hyperemia  in,  96 

evacuation    of  milk,  98 
operative   treatment,  99 
Pulmonary  tuberculosis,  174 

Kuhn's  lung  suction  mask  in, 

175,  176 
regulation   of   degree   of   ob- 
struction to  inspiration  in, 
175 
Pulse,   feeling   of,   in   obstructive 
hyperemia  by  elastic  bandage, 
26 
Pumps,  suction,  48 
Puncture,  lumbar,   improvement 
after,  209 
in  cerebrospinal      meningitis, 
with  hyperemic  treatment, 
173 
Pus,  evacuation  of,  in  phlegmon 
of  tendon-sheaths,  112 
in  treatment  of  acute  infec- 
tious inflammation  of  joints, 
103 
Pyorrhea    alveolaris,  obstructive 
hyperemia  in,  94 


Rabies,    obstructive    hyperemia, 

127 
Recurrent  osteomyelitis,  121 
Refracture,  83 
Rheumatism,  acute  articular,  172 

chronic  articular,  161 

of  shoulder,  hot-air  box  for, 
162 
Rhinology,   hyperemic   treatment 

in,  202 
Rice-corpuscles,  158 
Rules,  general,  26 


Sarcoma,  171 

Scars,  ugly,  preventive,  124 

Sciatica,  206 

hot-air  douche  for,  75 

Scoliosis,  166 

Sea-sickness,  182 

Seminal  vesicles,  tuberculosis  of, 
192 
vesiculitis,    189 

Senile  gangrene,  168 

Shoulder,  chronic   rheumatism  of, 
hot-air  box  for,  162 
hot-air  box  for,  68 
obstructive  hyperemia  by  elas- 
tic bandage  of,  37 

Sinuses,  accessory,  of  nose,  chronic 
diseases,  203 

Sinusitis,  acute  frontal,  202 
maxillary,  202 

Skin,  diseases  of,  210 
tuberculosis  of,  211 

Skull,  base  of,  compound  fractures 
of,  obstructive  hyperemia  in, 
129 

Snake-bites,  127 

Soft  tissues,  tuberculous  infiltra- 
tions of,  158 

Soiled  wounds,  obstructive  hy- 
peremia in,  122 

Spermatocystitis,  189 

Spina  ventosa,  151 

Spinal  anesthesia,  hyperemia  to 
prevent  after-effects,  128 


278 


INDEX 


Spinal  column  tuberculosis  of ,  145 

meningitis,  208 
Spine,  Pott's  disease  of,  145 

tuberculosis  of,  145 
Stauungs-hyperaemie,  23,  24.    See 

also  Obstructive  hyperemia. 
Stiffened   joints,   utility   of   large 
suction  apparatus  for  mobiliz- 
ing, 55 
Stiffness,  joint,  following  inflam- 
mation, 163 
brisement  force  in,  163 
Sty,  200 

suction  glass  for,  200 
Subcutaneous  phlegmon  of  arm, 

118  j 

Suction,  24  ! 

apparatus  for  elbow-joint,  62 
for  knee-joint,  62 
for  knee-stretching,  63  i 

for  nose,  203  I 

for  pes  varus,  164 
for  prostate,  189 
cup.  Klapp's,  87 
glass  for  puerperal  mastitis,  48, 
49 
for  sty,  200 
glasses,  46,  47,  50,  51 
for  cervix  uteri,  185 
for  tonsils,  204 
hyperemia  in  abscess,  90 
of  axilla,  91 
in  club-foot,  164 
in  furuncles  and  carbuncles 
84 
dressings  in,  85 
duration,  85 
incision  in,  85 
size  of  cups  in,  86 
in  diabetics,  87 
of  lip,  88 

technique,  88 
in  furunculosis,  86 
in  gynecologic  therapy,  184 
in  gynecology,  184 
indications,  185 
in  infected  wounds,  93 


Suction  hyperemia   in    inflamma- 
tory diseases  of  eyelids  and 
conjunctiva,  200 
in  locomotor  ataxia,  209 
in  lymphadenitis,  91 
in  pes  varus,  164 
in  posterior  parametritis,  186 
in  puerperal  mastitis,  96 

evacuation    of    milk    in, 

98 
operative  treatment,  99 
in  tuberculosis  of  joints,  133 
of  spine,  145 
mask,  lung,  175,  176 
massage  in  posterior     parame- 
tritis, 186 
obstructive  hyperemia  by,  44 
apparatus  of  large  size  in, 
54 
utility  for  mobilizing 
stiffened       joints, 
55 
disinfection  in,  49 
dressings  in,  53 
duration     of     application, 

52 
effect  of,  44 
in  abscess,  51 
mechanical  effect  of,  47 
technique,  45 
pumps,  48 
Suppression  of  infection,  21 
Suppuration,  avoidance  of,  21 
hastening  course  of,  22 
small  incisions  in,  "22 
Suppurative    cerebrospinal    men- 
ingitis, 173 
Surgery,  hyperemic  treatment  in, 

79 
Surgical     diseases     benefited     by 

Bier's  treatment,  164 
Sycosis,  210 

Sympathetic  ophthalmia,  200 
Synovial    tendon    sacs,  tubercu- 
losis of,  158 
Syphilis,  160 
Syphilitic  ulcer  of  leg,  161 ,  168 


iXD?:x 


279 


Temporal  bone,  acute   inflamma- 
tory processes  of,  195 
Tendon   sacs,    synovial,   tubercu- 
losis of,  158 
Tendon-sheaths  of  hand,  Klapp's 
incising  of,  for  infection.  111, 
112 
phlegmon    of,    106.     See     also 

Phlegmon  of  tendon-sheaths. 
tuberculosis  of,  158 
Tenosynovitis,  83 
Testicle,  obstructive  hyperemia  by 
elastic  bandage  of,  41 
tuberculosis  of,  153,  192 

cold  abscess  in,  treatment  of, 
154 
Thrombosis  of  veins,  167 
Tic  douloureux,  206 
Tightness  of  elastic  bandage,  27 
Tonsillitis,  acute,  203 
Tonsils,  hypertrophic,  205 
suction  glasses  for,  204 
Tooth-fistula,  95 
Traumatic  hydrops  of  knee,  80 
Traumatisms,  79 
Trigeminal       neuralgia,       hot-air 

douche  for,  74 
Tuberculosis,  131 

in  various  localities,  151 
of  ilio-sacral  joint,  146 
of  joints,  131 

ambulatory  treatment,  150 
cold    abscess    in,  treatment 

142 
contractures  in,  138 
contraindications  to  hypere- 
mia in,  147 
course   of,  under    hyperemic 

treatment,  140 
form  of  hyperemia  in,  133 
obstructive     hyperemia     in, 
133 
duration  of,  133 
technique,  135 
permissibility   of    using  dis- 
eased joints  in,  137 
stiffness  after  treatment,  151 


Tuberculosis  of  joint.s,  suction  hy- 
peremia in,  133 
of  knee,  cured.  141 
of  larynx,  205 
of  OS  sacrum,  146 
of  peritoneum,  159 
of  prostate,  191 

of   remaining   kidney  after  ne- 
phrectomy. 193 
of  seminal  vesicles.  192 
of  skin,  211 
of  spinal  column,  145 
of  spine,  145 

of  synovial  tendon  sacs,  158 
of  tendon-sheaths,  158 
of  testicle,  153,  192 

cold  abscess  in,  treatment  of, 
154 
pulmonary,  174 

Kuhn's  lung  suction  mask  in, 

175, 176 
regulation   of   degree   of   ob- 
struction to  inspiration  in, 
175 
urinary,  descending,  192 
Tuberculous     cerebrospinal   men- 
ingitis, 173 
glands,  abscesses  due  to,  152 
hydrops  of  knee,  80 
hygroma,  158 

infiltrations     of     soft     tis.sues, 
158 
Tumors,  170 

Typhoid     fever,     bone-metastasis 
following,  181 


Ulcer  of  leg,  168 

syphilitic,  161,  168 

venereal,  191 
Universal  boxes,  76 
Urethritis,   subacute    gonorrheal, 

190 
Urinary  tuberculosis,  descending, 

192 
Usefulness,  wide  field  of,  22 


280 


INDEX 


Varicose  veins,  167 
Veins,  thrombosis  of,  167 

varicose,  167 
Venereal  ulcer,  191 
Vesiculitis,  seminal,  189 

subacute  gonorrheal,  190 
Vomiting   after  etherization,  ob- 
structive  hyperemia  to  pre- 
vent, 128 

of  pregnancy,  hyperemia  for,r28 


Wandering  cold  abscesses,  153 


Warmth  in  obstructive  hyperemia 

by  elastic  bandage,  31 
Wounds,  granulating,  93 

infected,  obstructive  hyperemia 
in,  122 
suction  hyperemia  in,  93 
of  fingers  and   hands,  obstruc- 
tive hyperemia  in,  125 
during    operations,    obstruc- 
tive hyperemia  in,  126 
perforative,  of  joints,  104 
soiled,    obstructive    hyperemia 
in,  122 


N 


SAUNDERS'  BOOKS 


on 


GYNECOLOGY 

and 

OBSTETRICS 

W.  B,  SAUNDERS   COMPANY 

925  WALNUT  STREET  PHILADELPHIA 

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SAUNDERS*    TEXT-BOOKS    CONTINUE    TO    GAIN 

I^HE  list  of  text-books  recommended  in  the  various  colleges  again  shows  a 
*  decided  gain  for  the  Saonders  publications.  During  the  present 
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Ashton*s 
Practice  of  Gynecology 


The  Practice  of  Gynecology.     By  W.  Easterly  Ashton,  M.  D., 

LL.D.,  Professor  of   Gynecology  in  the   Medico-Chirurgical   College, 

Philadelphia.    Handsome  octavo  volume  of  1096  pages,  containing  1057 

original  line  drawings.     Cloth,  ^6.50  net;  Half  Morocco,  $8.00  net. 

THE    NEW   (3d)    EDITION 

THREE  EDITIONS  IN  EIGHTEEN  MONTHS 

Three  large  editions  of  Dr.  Ashton' s  work  have  been  required  in  eighteen 
months.  The  author  takes  up  each  procedure  necessary  to  gynecologic  work 
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any  non-medical  subject,  the  minutest  detail  being  explained  in  language  that 
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a  large  number  of  new  ones  have  been  introduced. 

Howard  A.  Kelly.  M.  D. 

Professor  of  Gynecology,  Johns  Hopkins  University 

"  It  is  different  from  anything  that  has  as  yet  appeared.  The  illustrations  are  particularly 
clear  and  satisfactory.  One  specially  good  feature  is  the  pains  with  which  you  describe  so 
many  details  so  often  left  to  the  imagination." 

Charles  B.  Penrose,  M.  D. 

Formerly  Professor  of  Gynecology  in  the  University  of  Pennsylvania 

"  I  know  of  no  book  that  goes  so  thoroughly  and  satisfactorily  into  all  the  details  of  every« 
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George  M.  Edebohls,  M.  D. 

Professor  of  Diseases  of  Women,  New  York  Post-Graduate  Medical  School 
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GYNECOLOGY  AND    OBSTETRICS 


Bandler*s 
Medical    Gynecology 


Medical  Gynecology.  By  S.  Wyllis  Handler,  M.  D.,  Adjunct 
Professor  of  Diseases  of  Women,  New  York  Post-Graduate  Medical 
School  and  Hospital.  Octavo  of  680  pages,  with  135  original  illus- 
trations.    Cloth,  $5.00  net ;  Half  Morocco,  ^6.50  net. 

JUST    READY 
EXCLUSIVELY    MEDICAL    GYNECOLOGY 

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for  him,  written  for  him,  and  illustrated  for  him.  There  are  many  gynecologic 
conditions  that  do  not  call  for  operative  treatment ;  yet,  because  of  lack  of  that 
special  knowledge  required  for  their  diagnosis  and  treatment,  the  general  practi- 
tioner has  been  unable  to  treat  them  intelligently.  This  work  gives  just  the  in- 
formation the  practitioner  needs.  It  not  only  deals  with  those  conditions  amen- 
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manner  of  introducing  the  pessary  being  clearly  described  and  illustrated  with 
original  pictures  that  show  plainly  the  correct  technic  of  this  procedure.  The 
chapters  on  Vaginal  and  Abdominal  Massage,  and  particularly  that  on  Artificial 
Hyperemia  and  Anemia,  are  extremely  valuable  to  the  practitioner.  They  express 
the  very  latest  advances  in  these  methods  of  treatment.  Hydrotherapy,  especially 
the  Ferguson  and  Nauheim  Baths,  are  treated  in  extenso,  and  Electrotherapy 
receives  the  full  consideration  its  importance  merits.  Pain  as  symptom  and  its 
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Conditions  in  Gynecology,  and  Pregnancy  and  Abortion. 


SAUNDERS'    BOOKS    ON 


Kelly  and  Noble's 

Gynecology 

and  Abdominal  Surgery 


Gynecology  and  Abdominal  Surgery.  Edited  by  Howard  A. 
Kelly,  M.  D.,  Professor  of  Gynecology  in  Johns  Hopkins  University ; 
and  Charles  P.  Noble,  M.  D.,  Clinical  Professor  of  Gynecology  in  the 
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VOLUME    II    JUST    ISSUED 
WITH  880  ILLUSTRATIONS   BY  HERMANN  BECKER  AND   MAX   BRODEL 

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embracing  operations  upon  the  stomach,  upon  the  intestines,  upon  the  liver  and 
bile-ducts,  upon  the  pancreas  and  spleen,  upon  the  kidneys,  ureter,  bladder,  and 
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OBSTETRICS. 


Webster's 
Text-Book  of  Obstetrics 


A  Text=Book  of  Obstetrics.  By  J.  Clarence  Webster,  M.|D.  (Edin.), 
F.  R.  C.  P.  E.,  Professor  of  Obstetrics  and  Gynecology  in  Rush  Medical 
College,  in  Affiliation  with  the  University  of  Chicago ;  Obstetrician  and 
Gynecologist  to  the  Presbyterian  Hospital,  Chicago.  Handsome  octavo 
volume  of  767  pages,  beautifully  illustrated,  including  many  in  colors. 
Cloth,  ;^5.oo  net;  Sheep  or  Half  Morocco,  ;^6.50  net. 

BEAUTIFULLY    ILLUSTRATED 

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the  active  practitioner.  The  anatomic  changes  accompanying  pregnancy,  labor, 
and  the  puerperium  are  described  more  fully  and  lucidly  than  in  any  other  text- 
book on  the  subject.  The  exposition  of  these  sections  is  based  mainly  upon 
studies  of  frozen  specimens,  in  which  department  the  author  has  had  a  larger 
experience  than  any  other  worker.  Unusual  consideration  is  given  to  embryo- 
logic  and  physiologic  data  of  importance  in  their  relation  to  obstetrics.  Great 
care  was  taken  in  the  selection  of  the  illustrations,  aiming  to  meet  the  varied  re- 
quirements of  both  the  undergraduate  and  the  practising  physician.  The  book 
expresses  the  most  advanced  thought  of  the  day. 


OPINIONS  OF  THE  MEDICAL  PRESS 


Medical  Record,  New  York 

"  The  author's  remarks  on  asepsis  and  antisepsis  are  admirable,  the  chapter  on  eclampsia 
is  full  of  good  material,  and  .  .  .  the  book  can  be  cordially  recommended  as  a  safe  guide." 

Buffalo  Medical  Journal 

"  As  a  practical  text-book  on  obstetrics  for  both  student  and  practitioner,  there  is  left  very 
little  to  be  desired,  it  being  as  near  perfection  as  any  compact  work  that  has  been  published." 

Dublin  Journal  of  Medical  Science 

"  Both  to  the  student  .  .  .  and  to  the  practitioner  who  requires  the  latest  opinion  on  any 
point  of  practice.  Dr.  Webster's  book  will  be  of  the  greatest  value." 


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Webster's 
Diseases  of  Women 

With  Beautiful  Illustrations 

A  Text-Book  of  Gynecology.  By  J.  Clarence  Webster,  M.  D. 
(Edin.),  F.  R.  C.  p.  E.,  Professor  of  Gynecology  and  Obstetrics  in  Rush 
Medical  College,  in  Affiliation  with  the  University  of  Chicago  ;  Obstetri- 
cian and  Gynecologist  to  the  Presbyterian  Hospital,  Chicago.  Large 
octavo  volume  of  712  pages,  with  372  magnificent  text-illustrations  and 
10  colored  plates.     Cloth,  $7.00  net;  Half  Morocco,  $8.50  net 

rOR   THE    PRACTITIONER 

This  entirely  new  work  on  diseases  of  women  is  based  on  Dr.  Webster's 
extended  clinical  experience,  and  unusual  prominence  is  given  to  the  scienti- 
fic basis  of  each  subject  under  consideration.  Special  endeavor  has  been  made 
to  include  all  the  important  original  investigations  of  recent  years,  so  that  the  work 
represents  the  present-day  knowledge  upon  a  subject  of  the  greatest  importance  to 
every  practitioner.  Indeed,  Dr.  Webster  has  written  this  work  especially  for  the 
general  practitioner,  discussing  the  clinical  features  of  the  subject  in  their  widest 
relations  to  general  practice  rather  than  from  the  standpoint  of  specialism.  The 
magnificent  illustrations,  three  hundred  and  seventy-two  in  number,  are  nearly  all 
original.  Drawn  by  expert  anatomic  artists  under  Dr.  Webster's  direct  super- 
vision, they  portray  the  anatomy  of  the  parts  and  the  steps  in  the  operations  with 
rare  clearness  and  exactness.  These  illustrations,  selected  because  of  their 
practical  and  technical  value,  form  a  rich  collection,  supplementing  a  text  of 
unusual  conciseness. 

Howard  A.  Kelly.  M.D.. 

Professor  of  Gynecology,  Johns  Hopkins  University. 

"  It  is  undoubtedly  one  of  the  best  works  which  has  been  put  on  the  market  within  recent 
years,  showing  from  start  to  finish  Dr.  Webster's  well-known  thoroughness.  The  illustrations 
are  also  of  the  highest  order. 


GYNECOLOGY  AND    OBSTETRICS 


Cullen's 
Adenomyoma  qf  the  Uterus 


Adenomyoma  of  the  Uterus.  By  Thomas  S.  Cullen,  M,  D., 
Associate  Professor  of  Gynecology,  Johns  Hopkins  University.  Octavo 
of  275  pages,  with  original  illustrations  by  Hermann  Becker  and 
August  Horn.     Cloth,  $5.00  net;    Half  Morocco,  ^6.50  net. 

JUST    READY— A    NEW    WORK 

Dr.  Cullen's  large  clinical  experience  and  his  extensive  original  work  along 
the  lines  of  gynecologic  pathology  have  enabled  him  to  present  his  subject  with 
originality  and  precision.  The  work  gives  the  early  literature  on  adenomyoma, 
traces  the  disease  through  its  various  stages,  and  then  gives  the  detailed  findings 
in  a  large  number  of  cases  personally  examined  by  the  author.  Formerly  the 
physician  and  surgeon  were  unable  to  determine  the  cause  of  uterine  bleeding,  but 
after  following  closely  the  clinical  course  of  the  (disease,  Dr.  Cullen  has  found  that 
the  majority  of  these  cases  can  be  diagnosed  clinically.  The  results  of  these 
observations  he  presents  in  this  work.  The  superb  illustrations  are  the  work  of 
Mr.  Hermann  Becker  and  Mr.  August  Horn,  of  the  Johns  Hopkins  Hospital. 

The  Lancet,  London 

"  A  good  example  of  how  such  a  monograph  should  be  written.  It  is  an  excellent  work, 
worthy  of  the  high  reputation  of  the  author  and  of  the  school  from  which  it  emanates." 


The  American 
Text-Book  qf  Obstetrics 

The    New  (2d)   Edition 


The  American  Text-Book  of  Obstetrics.  In  two  volumest  Edited 
by  Richard  C.  Norris,  M,  D.  ;  Art  Editor,  Robert  L.  Dickinson,  M.  D. 
Two  octavos  of  about  600  pages  each;  nearly  900  illustrations,  includ- 
ing 49  colored  and  half-tone  plates.  Per  volume:  Cloth,  ;^3.50  net; 
Half  Morocco,  ;^4.50  net. 

American  Journal  of  the  Medical  Sciences 

"  As  an  authority,  as  a  book  of  reference,  as  a  '  working  book  '  for  the  student  or  practi- 
tioner, we  commend  it  because  we  believe  there  is  no  better." 


SAUNDERS'   BOOKS   ON 


Hirst's 
Text-Book  of  Obstetrics 

New(5th)  Edition,  Revised 


A  Text-Book  of  Obstetrics.  By  Barton  Cooke  Hirst,  M.  D., 
Professor  of  Obstetrics  in  the  University  of  Pennsylvania.  Handsome 
octavo,  915  pages,  with  767  illustrations,  40  of  them  in  colors.  Cloth, 
^5.00  net;  Sheep  or  Half  Morocco,  $6.50  net. 

WITH    767    ORIGINAL    ILLUSTRATIONS 

Immediately  on  its  publication  this  work  took  its  place  as  the  leading  text-book 
on  the  subject.  Both  in  this  country  and  in  England  it  is  recognized  as  the  most 
satisfactorily  written  and  clearly  illustrated  work  on  obstetrics  in  the  language. 
The  illustrations  form  one  of  the  features  of  the  book.  They  are  numerous  and 
the  most  of  them  are  original.  In  this  edition  the  book  has  been  thoroughly  revised. 
More  attention  has  been  given  to  the  diseases  of  the  genital  organs  associated  with 
or  following  childbirth.  Many  of  the  old  illustrations  have  been  replaced  by  better 
ones,  and  there  have  been  added  a  number  entirely  new.  The  work  treats  the 
subject  from  a  clinical  standpoint. 


OPINIONS  or  THE  MEDICAL  PRESS 


British  Medical  Journal 

'*  The  popularity  of  American  text-books  in  this  country  is  one  of  the  features  of  recent 
years.  The  popularity  is  probably  chiefly  due  to  the  great  superiority  of  their  illustrations 
over  those  of  the  English  text-books.  The  illustrations  in  Dr.  Hirst's  volume  are  far  more 
numerous  and  far  better  executed,  and  therefore  more  instructive,  than  those  commonly 
found  in  the  works  of  writers  on  obstetrics  in  our  own  country." 

Bulletin  of  Johns  Hopkins  Hospital 

"  The  work  is  an  admirable  one  in  every  sense  of  the  word,  concisely  but  comprehensively 
written." 

The  MeiUcal  Record,  New  York 

"The  illustrations  are  numerous  and  are  works  of  art,  many  of  them  appearing  for  the  first 
time.  The  author's  style,  though  condensed,  is  singularly  clear,  so  that  it  is  never  necessary 
to  re-read  a  sentence  in  order  to  grasp  the  meaning.  As  a  true  model  of  what  a  modern  text- 
book on  obstetrics  should  be,  we  feel  justified  in  affirming  that  Dr.  Hirst's  book  is  withowt  a 
rival." 


DISEASES   OF   WOMEN. 


HirstV 
Diseases  of  Women 


A  Text-Book  of  Diseases  of  Women.  By  Barton  Cooke  Hirst, 
M.  D.,  Professor  of  Obstetrics,  University  of  Pennsylvania ;  Gynecolo- 
gist to  the  Howard,  the  Orthopedic,  and  the  Philadelphia  Hospitals. 
Octavo  of  745  pages,  with  701  original  illustrations,  many  in  colors. 
Cloth,  ;^5.oo  net;  Half  Morocco,  $6.^0  net. 

THE    NEW  (2d)    EDITION 
WITH    701    ORIGINAL    ILLUSTRATIONS 

The  new  edition  of  this  work  has  just  been  issued  after  a  careful  revision. 
As  diagnosis  and  treatment  are  of  the  greatest  importance  in  considering  diseases 
of  women,  particular  attention  has  been  devoted  to  these  divisions.  To  this  end, 
also,  the  work  has  been  magnificently  illuminated  with  701  illustrations,  for  the 
most  part  original  photographs  and  water-colors  of  actual  clinical  cases  accumu- 
lated during  the  past  fifteen  years.  The  palliative  treatment,  as  well  as  the 
radical  operative,  is  fully  described,  enabling  the  general  practitioner  to  treat 
many  of  his  own  patients  vathout  referring  them  to  a  specialist.  An  entire  sec- 
tion is  devoted  to  a  full  description  of  all  modern  gynecologic  operations,  illumi- 
nated and  elucidated  by  numerous  photographs.  The  author's  extensive  ex- 
perience renders  this  work  of  unusual  value. 


OPINIONS  OF  THE  MEDICAL  PRESS 


Medical  Record,  New  York 

"  Its  merits  can  be  appreciated  only  by  a  careful  perusal.  .  .  .  Nearly  one  hundred  pages 
are  devoted  to  technic,  this  chapter  being  in  some  respects  superior  to  the  descriptions  in 
many  other  text-  boks." 

Boston  M^ical  tund  Surgical  Journal 

"The  author  has  given  special  attention  to  diagnosis  and  treatment  throughout  the  book, 
and  has  produced  a  practical  treatise  which  should  be  of  the  greatest  value  to  the  student,  the 
general  practitioner,  and  the  specialist." 

Medical  News,  New  York 

•    "  Office  treatment  is  given  a  due  amount  of  consideration,  so  that  the  work  will  be  as 
useful  to  the  non-operator  as  to  the  specialist." 


SAUNDERS"    BOOKS   ON 


OCT  A  •  THE  NEW 

THE  BEST  /\  m  6  r  1  C  Sill  STANDARD 

Illustrated   Dictionary 

The    New   (4th)    Edition 


The  American  Illustrated  Medical  Dictionary.  A  new  and  com- 
plete dictionary  of  the  terms  used  in  Medicine,  Surgery,  Dentistry, 
Pharmacy,  Chemistry,  and  kindred  branches;  with  over  loo  new  and 
elaborate  tables  and  many  handsome  illustrations.  By  W,  A.  Newman 
Borland,  M.  D.,  Editor  of  "  The  American  Pocket  Medical  Diction- 
ary." Large  octavo,  nearly  850  pages,  bound  in  full  flexible  leather. 
Price,  ;$4.50  net;  with  thumb  index,  $5.00  net. 

Gives  a  Maximum  Amount  of  Matter  m  a  Minimum  Space,  euid  at  the  Lowest 

Possible  Co0t 

WITH  aooo  NEW  TERMS 

The  immediate  success  of  this  work  is  due  to  the  special  features  that  distin- 
guish it  from  other  books  of  its  kind.  It  gives  a  maximum  of  matter  in  a  mini- 
mum space  and  at  the  lowest  possible  cost.  Though  it  is  practically  unabridged, 
yet  by  the  use  of  thin  bible  paper  and  flexible  morocco  binding  it  is  only  \}^ 
inches  thick.  The  result  is  a  truly  luxurious  specimen  of  book-making.  In  this 
new  edition  the  book  has  been  thoroughly  revised,  and  upward  of  fifteen  hundred 
new  terms  that  have  appeared  in  recent  medical  literature  have  been  added,  thus 
bringing  the  book  absolutely  up  to  date.  The  book  contains  hundreds  of  terms 
not  to  be  found  in  any  other  dictionary,  over  loo  original  tables,  and  many  hand- 
some illustrations,  a  number  in  colors. 


PERSONAL   OPINIONS 


Howard  A.  Kelly.  M.  D.. 

Professor  of  Gynecology,  Johns  Hopkins  University,  Baltimore. 

"  Dr.  Borland's  dictionary  is  admirable.     It  is  so  well  gotten  up  and  of  such  convenient 
sise.     No  errors  have  been  found  in  my  use  of  it." 

J.  Collins  Warren,  M.D.,  LL.D.,  F.R.C.S.  (Hon.) 

Professor  of  Surgery^  Harvard  Medical  School. 

"  I  r^ard  it  as  a  valuable  aid  to  my  medical  literary  work.    It  is  very  complete  and  of 
convenient  size  to  handle  comfortably.     I  use  it  in  preference  to  any  other." 


GYNECOLOGY  AND    OBSTETRICS 


Penrose's 
Diseases  of  Women 

Sixth    Revised    Edition 


A  Text- Book  of  Diseases  of  Women.  By  Charles  B,  Penrose, 
M.  D.,  Ph.  D.,  formerly  Professor  of  Gynecology  in  the  University  of 
Pennsylvania ;  Surgeon  to  the  Gynecean  Hospital,  Philadelphia.  Oc- 
tavo volume  of  550  pages,  with  225  fine  original  illustrations.  Cloth, 
;^3-75  net. 

JUST    ISSUED 

Regularly  every  year  a  new  edition  of  this  excellent  text-book  is  called  for, 
and  it  appears  to  be  in  as  great  favor  with  physicians  as  with  students.  Indeed, 
this  book  has  taken  its  place  as  the  ideal  work  for  the  general  practitioner.  The 
author  presents  the  best  teaching  of  modern  gynecology,  untrammeled  by  anti- 
quated ideas  and  methods.  In  every  case  the  most  modem  and  progressive 
technique  is  adopted,  and  the  main  points  are  made  clear  by  excellent  illustra- 
tions. The  new  edition  has  been  carefully  revised,  much  new  matter  has  been 
added,  and  a  number  of  new  original  illustrations  have  been  introduced.  In  its 
revised  form  this  volume  continues  to  be  an  admirable  exposition  of  the  present 
status  of  gynecologic  practice. 


PERSONAL  AND  PRESS  OPINIONS 


Howard  A.  Kelly.  M.  D.. 

Professor  of  Gynecology  and  Obstetrics,  Johns  Hopkins  University,  Baltimore. 
"  I  shall  value  very  highly  the  copy  of  Penrose's  '  Diseases  of  Women  '  received.     I  have 
already  recommended  it  to  my  class  as  THE  BEST  book." 

E.  E.  Montgomery,  M.  D., 

Professor  of  Gynecology,  Jefferson  Medical  College,  Philadelphia. 
"  The  copy  of '  A  Text-Book  of  Diseases  of  Women  '  by  Penrose,  received  to-day.     I  have 
looked  over  it  and  admire  it  very  much.     I  have  no  doubt  it  will  have  a  large  sale,  as  it  justly 
merits." 

Bristol  Medico-Chirur^cal  JotimeJ 

"  This  is  an  excellent  work  which  goes  straight  to  the  mark.  .  .  .  The  book  may  be  taken 
as  a  trustworthy  exposition  of  modern  gynecology." 


««  SAUNDERS'    BOOKS   ON 

Dorland*s 
Modern  Obstetrics* 


Modem  Obstetrics :  General  and  Operative.     By  W.  A.  Newman 

DoRLAXD.  A.  M.,  M.  D.,  Assistant  Instructor  in  Obstetrics,  Univer- 
sity of  Pennsylvania;  Associate  in  Gynecology  in  the  Philadelphia 
Polyclinic.  Handsome  octavo  volume  of  797  pages,  with  201  illustra- 
tions.    Cloth,  $4.00  r^L 

Second  Edition,  Revised  and  Greatly  Cnieirged 

In  t^T'^  edition  the  book  has  been  entirely  rewritten  and  very  greatly  enlaiged. 
Amongthe  new  subjects  introduced  are  the  sxirgical  treatment  of  puerperal  s^»ts, 
infant  mortality,  placental  transmission  of  diseases,  serum-therapy  of  puerperal 
sepsis,  etc.  By  new  illustrations  the  text  has  been  elucidated,  and  the  subject  jwe- 
sented  in  a  most  instructive  and  acceptable  form. 

Jovmal  of  &e  Aaerican  Mfdirwl  Asaociatioa 

"  Tbis  work  deserves  comnteiuiation,  and  that  it  has  received  wttat  it  deserves  at  'die  kaadk 
of  tiie  profession  is  attested  fay  the  feet  that  a  second  edition  is  called  for  within  such  a  dioit 
toae.     Especially  deserving  of  p>raise  is  die  chapter  on  paerperal  sepsis." 

Davis'  Obstetric  and 
Gynecologic  Nursing 

Obstetric  and  <jynecolo^c  Nursing.  By  Edward  P.  Davt^s,  A.  M^ 
M.  D.,  Professor  of  Obstetrics  in  the  Jefferson  Medical  College  and 
Philadelphia  Polyclinic ;  Obstetrician  and  Gynecologist,  Philadelphia 
Hospital.     i2mo  of  436  pages,  illustrated.     Buckram,  tl.Jl  net 

RECENTLY    ISSUED— NEW    f3d)    EDITION 

Obstetric  nursing  demands  some  knowledge  of  natural  pregnane^',  and  gyne- 
cologic nursing,  really  a  branch  of  surgical  nursing,  requires  special  instructicn 
and  training.  This  volinne  presents  this  information  in  the  most  conrenient 
form.  This  third  edition  has  been  very  carefiilly  revised  throughout,  bringing  the 
subject  down  to  date. 

The  Lancet.  London 

"  Not  only  nurses,  bat  even  newly  qualified  medical  men.  woaM  learn  a  great  deal  bym 
perusal  of  this  book.     It  is  written  in  a  clear  and  pleasant  style,  and  is  a  work  we  «■««»  re 
mend." 


GYXECOLOGY  AND    OBSTETRICS.  13 

Garrigues* 
Diseases  of  Women 

Third  Edition,  Thoroughly  Revised 


A  Text-Book  of  Diseases  of  Woiii«i.  By  Henry  J.  G.\rrigues, 
A.  M.,  M.  D.,  Gynecologist  to  St  Mark's  Hospital  and  to  the  German 
Dispensan',  New  York  City.  Handsome  octavo,  756  pages,  with  367 
engraxings  and  colored  plates.  Cloth,  ^$4.50  net;  Sheep  or  Half 
Morocco,  $6.00  net 

The  first  two  editions  of  this  work  met  with  a  most  appreciative  reception  by 
the  medical  profession  both  in  this  country'  and  abroad.  In  this  edition  the  entire 
work  has  been  carefidly  and  thoroughly  re\-ised.  and  considerable  new  matter 
added,  bringing  the  work  precisely  down  to  date.  Many  new  illustrations  have  been 
introduced,  thus  greatiy  increasing  the  value  of  the  book  both  as  a  text-book  and 
book  of  reference. 

Thad.  A.  Reaaay.  M.  D..  Professor  of  Cliiiu\il  Grnearlcgy,  MedieaJ  College  of  Ohio. 

"One  <rf  the  best  text-books  for  students  and  practitioners  which  has  been  published  in  the 
English  language ;  it  is  condensed,  dear,  and  comprehensive.  The  profound  learning  and 
great  clinical  experience  of  the  distinguished  author  find  expression  in  this  book." 


American 
Text-Book  of  Gynecology 

American  Text-Book  of  Gynecology :  Medical  and  Surgical. 
Edited  by  J.  M.  Baldy,  M.  D.,  Professor  of  Gv-necologA",  Philadelphia 
Polyclinic.  Imperial  octavo  of  718  pages,  with  341  text-illustrations 
and  38  plates.     Cloth,  56.00  net;  Half  Morocco,  $7.50  net. 

SECOND  REVISED  EDITION 

This  volume  is  thoroughly  practical  in  its  teachings,  and  is  intended  to  be  a 

working  text-book  for  physicians  and  students.     Many  of  the  most  important 

subjects  axe  considered  from  an  entirely  new  standpoint,  and  are  grouped  together 

in  a  maimer  somewhat  foreign  to  the  accepted  custom. 

BoatoB  HeAal  and  Surreal  Jotsnal 

"The  most  complete  exponent  of  gjrnecolc^y  which  we  have.  No  subject  seems  to  have 
been  n^kcted." 


14  SAUNDERS'    BOOKS   ON 

Schaffer  and  Edgar's  Labor  and  Operative  Obstetrics 

Atlas  and    Epitome  of    Labor    and    Operative    Obstetrics.      By   Dr. 

O.  Schaffer,  of  Heidelberg.  Edited,  with  additions,  "by  J.  Clifton  Edgar, 
M.  D.,  Professor  of  Obstetrics  and  Clinical  Midwifery,  Cornell  University 
Medical  School,  New  York.  With  14  lithographic  plates  in  colors,  139  text- 
cuts,  and  III  pages  of  text.     Cloth,  $2.00  net.     In  Saunders'  Hand-Atlases. 

American  Medicine 

"  It  would  be  difficult  to  find  one  hundred  pages  in  better  form  or  containing  more 
practical  points  for  students  or  practitioners." 

Schaffer     and     Edgar's     Obstetric     Diagnosis     and 
Treatment 

Atlas  and  Epitome  of  Obstetric  Diagnosis  and   Treatment.    By  Dr. 

O.  Schaffer,  of  Heidelberg.  Edited,  with  additions,  by  J.  Clifton  Edgar, 
M.  D.,  Professor  of  Obstetrics  and  Clinical  Midwiferj',  Cornell  University 
Medical  School,  New  York.  With  122  colored  figures  on  56  plates,  38  text- 
cuts,  and  315  pages  of  text.      Cloth,   53- 00  net.      Saunders'  Hand- Atlases. 

New  York  Medical  Journal 

"The  illustrations  are  admirably  executed,  as  they  are  in  all  of  these  atlases,  and  the  text 
can  safely  be  commended." 

Schaffer  and  Norris'  Gynecolo^ 

Atlas  and  Epitome  of  Gynecology.  By  Dr.  O.  Scmaffer,  of  Heidel- 
berg. Edited,  with  additions,  by  Richard  C.  Norris,  A.  M.,  M.  D,, 
Gynecologist  to  Methodist  Episcopal  and  Philadelphia  Hospitals.  With  207 
colored  figures  on  90  plates,  65  text-cuts,  and  308  pages  of  text.  Cloth, 
%1. 50  net.      In  Saunders'  Hand- Atlas  Series. 

American  Journal  of  the  Medical  Sciences 

"  Of  the  illustrations  it  is  difficult  to  speak  in  too  high  terms  of  approval.  They  are  so 
clear  and  true  to  nature  that  the  accompanying  explanations  are  almost  superfluous." 

Galbraith's  Four  Epochs  of  Woman's  Life 

New  (2d)  Edition 

The  Four  Epochs  of  Woman's  Life :  A  Study  in  Hygiene.  By  Anna 
M.  Galbraith,  M.  D.,  Fellow  of  the  New  York  Academy  of  Medicine,  etc. 
With  an  Introductory  Note  by  John  H.  Musser,  M.  D.,  University  of 
Pennsylvania.      i2mo  of  247  pages.     Cloth,  ^1.50  net. 

Birmingham  Medical  Review,  Englsund 

"  We  do  not,  as  a  rule,  care  for  medical  books  written  for  the  instruction  of  the  public. 
But  we  must  admit  that  the  advice  in  Dr.  Galbraith's  work  is,  in  the  main,  wise  and 
wholesome." 


GYNECOLOGY  AND    OBSTETRICS.  15 

Schaffer  and  Webster's 
Operative  Gynecology 


Atlas  and  Epitome  of  Operative  Gynecology.  By  Dr.  O,  Schaf- 
fer, of  Heidelberg.  Edited,  with  additions,  by  J.  Clarence  Webster, 
M.D.  (Edin.),  F.R.C.P.E.,  Professor  of  Obstetrics  and  Gynecology  in 
Rush  Medical  College,  in  affiliation  with  the  University  of  Chicago, 
42  colored  lithographic  plates,  many  text-cuts,  a  number  in  colors,  and 
138  pages  of  text.     In  Saunders'  Hand-Atlas  Series.    Cloth,  ^3.00  net. 


Much  patient  endeavor  has  been  expended  by  the  author,  the  artist,  and  the 
lithographer  in  the  preparation  of  the  plates  of  this  atlas.  They  are  based  on 
hundreds  of  photographs  taken  from  nature,  and  illustrate  most  faithfully  the 
various  surgical  situations.  Dr.  Schaffer  has  made  a  specialty  of  demonstrating 
by  illustrations. 

Medical  Record,  New  York 

"  The  volume  should  prove  most  helpful  to  students  and  others  in  grasping  details  usually 
to  be  acquired  only  in  the  amphitheater  itself." 

De  Lee's 
Obstetrics  for  Nurses 


Obstetrics  for  Nurses.  By  Joseph  B.  De  Lee,  M.D.,  Professor  of 
Obstetrics  in  the  Northwestern  University  Medical  School ;  Lecturer 
in  the  Nurses'  Training  Schools  of  Mercy,  Wesley,  Provident,  Cook 
County,  and  Chicago  Lying-in  Hospitals.  i2mo  volume  of  5  12  pages, 
fully  illustrated.  Cloth,  $2.50  net. 

RECENTLY    ISSUED— NEW   (3d)    EDITION 

While  Dr.  De  Lee  has  written  his  work  especially  for  nurses,  yet  the  prac- 
titioner will  find  it  useful  and  instructive,  since  the  duties  of  a  nurse  often  devolve 
upon  him  in  the  early  years  of  his  practice.  The  illustrations  are  nearly  all 
original,  and  represent  photographs  taken  from  actual  scenes.  The  text  is  the 
result  of  the  author's  many  years'  experience  in  lecturing  to  the  nurses  of  five 
different  training  schools. 

J.  Clifton  Ed^&r.  M.  D., 

Professor  of  Obstetrics  and  Clinical  Midwifery,  Cornell  University .  New  York. 
"  It  is  far  and  away  the  best  that  has  come  to  my  notice,  and  I  shall  take  great  pleasure  in 
recommending  it  to  my  nurses,  and  students  as  well." 

J 


i6      SAUNDERS'  BOOKS  ON  GYNECOLOGY  AND  OBSTETRICS. 

American  Pocket  Dictionary  ^"*£ctna/wd 

The  American  Pocket  Medical  Dictionary.  Edited  by  W. 
A.  Newman  Borland,  A.M.,  M.  D.,  Assistant  Obstetrician  to  the 
Hospital  of  the  University  of  Pennsylvania ;  Fellow  of  the  American 
Academy  of  Medicine.  Over  570  pages.  Full  leather,  limp,  with 
gold  edges.     ^1.00  net;  with  patent  thumb  index,  ^1.25  net. 

James  W.  Holland.  M.  D.. 

Professor  of  Medical   Chemistry   and    Toxicology   at  the  Jefferson   Medical   College, 
Philadelphia. 

"  I  am  struck  at  once  with  admiration  at  the  compact  size  and  attractive  exterior.  J 
can  recommend  it  to  our  students  without  reserve." 

Cragin's  Gynecology.  New  (6th)  Edition 

Essentials  of  Gynecology.  By  Edwin  B.  Cragin,  M.  D., 
Professor  of  Obstetrics,  College  of  Physicians  and  Surgeons,  New 
York,  Crown  octavo,  215  pages,  62  illustrations.  Cloth,  ;^i.oo 
net.     In  Saunders'   Question- Compend  Series. 

The  'Medical  Record,  New  York 

"  A  handy  volume  and  a  distinct  improvement  of  students'  compends  in  general. 
No  author  who  was  not  himself  a  practical  gynecologist  could  have  consulted  the 
student's  needs  so  thoroughly  as  Dr.  Cragin  has  done." 

AshtOn'S    Obstetrics.  New  (6th)  Edition 

Essentials  of  Obstetrics.  By  W.  Easterly  Ashton,  M.D., 
Professor  of  Gynecology  in  the  Medico-Chirurgical  College,  Phila- 
delphia. Crown  octavo,  256  pages,  75  illustrations.  Cloth,  ;^i.oo 
net.     In  Saunders'  Question- Compend  Set'ies. 

Southern  Practitioner 

"  An  excellent  little  volume  containing  correct  and  practical  knowledge.  An  admir- 
able compend,  and  the  best  condensation  we  have  seen." 

Barton  and  Wells'  Medical  Thesaurus 

A  Thesaurus  of  Medical  Words  and  Phrases.  By  Wilfred 
M.  Barton,  M.  D.,  Assistant  to  Professor  of  Materia  Medica  and 
Therapeutics,  Georgetown  University,  Washington,  D.  C. ;  and 
Walter  A.  Wells,  M.  D.,  Demonstrator  of  Laryngology,  George- 
town University,  Washington,  D.  C.  i2mo  of  534  pages.  Flex- 
ible leather,  $2.50  net ;  with  thumb  index,  ;^3.oo  net. 


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